Tuesday, August 26, 2014

Shattered Worlds/Psychotic States: A Post-Cartesian View of the Experience of Personal Annihilation


Many longtime readers of this blog are aware of my infatuation with the work of the intersubjectivist, relational psychoanalyst, George Atwood, a man who has specialized in working with psychosis in a field that once believed psychosis is untreatable.

The text below is from an article by Atwood, Donna Orange, and Robert Stolorow, Shattered Worlds/Psychotic States: A Post-Cartesian View of the Experience of Personal Annihilation, that appeared in the Spring 2002 issue of Psychoanalytic Psychology, 19(2), pages 281-306. Atwood is the lead author on this piece, which in their work indicates that these are predominantly his ideas. The paper was downloaded from his page, linked to above.

I deeply appreciate the relational context in which they view the symptoms of psychosis. Rather than seeing it as a brain disease, as does the majority of mental health professionals, they understand that, fundamentally, "the experience of personal annihilation reflects an intersubjective catastrophe in which psychologically sustaining relations to others have broken down at their most fundamental level" (Working Intersubjectively: Contextualism in Psychoanalytic Practice, Orange, Atwood, & Stolorow, 1997). I have seen, in depth, how this loss of psychologically sustaining relationships can push someone into a mind-state we have named psychosis.

[That book, by the way, is one of the best introductions to the intersubjective-systems theory of relational psychoanalysis.]

The text below offers one of the most succinct and compassionate elucidations of the subjective experience of psychosis.

The Experience of Personal Annihilation

An aura of impenetrability has always surrounded the psychoses, which have seemed far removed from ordinary experience and therefore extremely difficult or even impossible to reach empathically. This felt difficulty is indeed inherent in the very definition of these conditions, insofar as their essential feature is regarded as being a departure from the putatively true and real world a normal person inhabits. The obstacles to establishing empathy for the subjective states appearing in this extreme range of psychological disorder, however, are not in our view solely attributable to the experiences involved being at some distant remove from the average, normal life of a human being. A very powerful impediment arises from an altogether different source, namely, the assumptions of the observing clinician about the nature of experience itself and ultimately about the nature of a person. When one is regarded as possessing a mind, and this mind in turn is conceived as having an interior that is occupied by conscious (and perhaps unconscious) psychic contents, a structure is being imposed that sharply delineates the boundaries of one's personhood in respect to an objectively real outer world. Such a picture dichotomizes the subjective field into an inside and an outside, reifies and rigidifies the distinction between them, and envisions the resulting structure as constitutive of human existence in general.

Once we understand how the Cartesian view of the person reifies and universalizes this very specific pattern of experience, we can also see why the subjective states that appear so prominently in the psychoses could never be adequately encompassed by a conceptual system resting on Cartesian premises. These states include experiences of the dissolution of boundaries demarcating I and not-I, of the fragmentation and dispersal of one's very identity, and of the disintegration of reality itself. A phenomenological framework, by contrast, is unencumbered by objectifying images of mind, psyche, or psychical apparatus, and is therefore free to study experience without evaluating it for its veridicality with respect to a presumed external reality. The exploration of annihilation states accordingly presents no special philosophical difficulty, for we are concerned then only with the person and his or her world, in whatever state they may present themselves.

In the study of psychological annihilation, one may focus on self-experience or, more broadly, on world experience, where the former is seen as a central area included within the latter. Experiences of self and world are inextricably bound up with one another, in that any dramatic change in the one necessarily entails corresponding changes in the other. Self-dissolution, for example, is not a subjective event that could leave the world of the individual otherwise intact, with the selfhood of the person somehow subtracted out. The experience of self-loss means the loss of an enduring center in relation to which the totality of the individual's experiences are organized. The dissolution of one's selfhood thus produces an inevitable disintegrating effect on the person's experience in general, and results ultimately in the loss of coherence of the world itself. Likewise, the breakup of the unity of the world means the loss of a stable reality in relation to which the sense of self is defined and sustained, and an experience of self-fragmentation inevitably follows in its wake. World disintegration and self-dissolution are thus inseparable aspects of a single process, two faces of the same psychological catastrophe.

The experience of annihilation lies at the heart of the psychoses, and this is often expressed directly in statements to the effect that the person is dead or dying, that he or she has no self, does not exist, or is absent rather than present. It is also frequently said that the world is not real, that it has broken apart into pieces, and even that it is coming to an end. Sometimes the destruction of one's personal reality appears in an experience of falling forever, of spinning out of control, of shrinking endlessly and disappearing, or of being swallowed up into the environmental surround. More commonly, however, reparative and restorative efforts to reestablish a sense of existing predominate in the clinical picture, and these efforts appear in a wide variety of forms. A sense of being or becoming unreal, for example, gives rise to a preoccupation with one's mirror reflection, as if sustained attention to the visual outline of one's bodily being could compensate for a vanishing sense of personal selfhood. The experience of a deadness at the core of one's existence leads to asearch for a counteracting sense of aliveness, provided by the intensity of sensation in self-inflicted pain, in bizarre sexuality, or in thrilling, death-defying adventures. The dissolving of bodily boundaries and a terrifying feeling of melting into one's surroundings occasions the wearing of multiple sets of clothing, one on top of the next, expressing an attempt to reestablish and protect a devastated sense of bounded self-integrity. A breakup in the felt continuity of personal identity over time brings about an obsession with recalling and mentally reliving large numbers of events from the recent and remote past, the calling up of the various events embodying an effort to bring the temporally separated fragments of history together into a single whole. An experience of the disintegration of reality itself, of the falling apart of the world into a jumble of unconnected perceptions and meaningless happenings, gives way to delusions of reference in which the isolated elements are woven back together and given a sinister, directly personal significance. Small changes in the appearance of familiar persons seem to indicate global changes and breaches of identity, heralding the fragmentation of the world's stability into temporal chaos, and these breaks in continuity are repaired and smoothed over by the delusional idea that these persons have somehow been replaced by nefarious imposters. In each of these instances, a countervailing effort to reintegrate a fragmenting world and restore a sense of continuous and coherent being is most salient, while the underlying annihilation state recedes into the background.

In other cases, the annihilation itself is foregrounded, often in vividly concrete symbols, so that images of personal destruction pervade and dominate the individual's experience. Here the extremes to which the concretization is carried assist in maintaining the state of one's dissolving selfhood in focal awareness. The image of being poisoned by deadly chemicals or invisible gases, for example, concretely portrays a sense of being infiltrated and then killed off by the impinging, intrusive impacts of the social surround. Picturing a distant machine that sends influencing rays into one's mind and body, likewise, articulates an experience of the loss of agency [3] and of falling under the obliterating control of an alien agenda. Murdering assassins or conspiring government agents are imagined, and these figures concretize the threat of psychological obliteration in the face of irresistible pressures from emotionally significant others. A takeover of one's brain by a supernatural entity is suddenly felt to occur, symbolizing an overpowering invalidation and usurpation of one's subjectivity.

Sometimes the imagery of annihilation is intermixed with or even supplanted by what appear to be grandiose or highly idealized visions of oneself or others. These latter images express efforts to resurrect all those parts of one's selfhood and world that have become subject to shattering and erasure. The concepts of grandiosity and idealization are, however, problematic when understood in the context of the phenomenology of personal annihilation. Identifying a particular experience as idealized or grandiose involves a judgment and a standard defining what is and is not reasonable for a person to believe. Grandiosity means appropriating to oneself a significance, power, and perfection one actually does not possess. Idealization, as this term is traditionally employed, means correspondingly exaggerating the significance and perfection of some emotionally important other. In the context of personal annihilation, however, it cannot be said that so-called idealization and grandiosity appropriate or exaggerate anything. What appears, from an external point of reference, to be an outrageous exaggeration, may, subjectively regarded, be understood as accentuating the sense that one exists, that one possesses agency and subjectivity, that one's experiences belong to no one other than oneself, and that one's personal world has coherence and is enduringly real. A delusional claim to be the owner of the world, for example, may contain at its core a dissolving sense of one's perceptions and thoughts being one's own. Seemingly extravagant assertions of personal achievement and capability may crystallize and intensify an otherwise threatened experience of agency and autonomy. Visions of descending from a royal lineage or of being a specially chosen child of God accentuate and protect a disappearing sense of connection to a world-sustaining other. An idea that one has penetrated the ultimate secret of the cosmos, the key to understanding the interrelationships of all existing things, enshrines and preserves the integrity of one's personal world in the face of a threat of its total disintegration. In each of these last examples, the problematic issue is not that unrealistic grandiose or idealized qualities are being ascribed to oneself or others; it is rather that the individual's personal universe has come under assault and is in danger of annihilation. Let us turn now to the intersubjective contexts in which the experiences we have been describing take form.

The Intersubjective Context of Annihilation

In Working Intersubjectively: Contextualism in Psychoanalytic Practice (Orange, Atwood, & Stolorow, 1997), we said that the experience of personal annihilation reflects an intersubjective catastrophe in which psychologically sustaining relations to others have broken down at their most fundamental level. In what does this breakdown consist? It consists in the loss of affirming, validating connections to others and the shattering of the subjective world by impingement and usurpation. Although the concrete events and life circumstances playing a role in the origin of annihilation states are highly varied, they have in common an effect of undermining one's sense of existing and of being real in its most basic aspects, including the experience of oneself as being an active agent and subject, as possessing an identity that is coherent and felt as authentically one's own, as having a boundary delineating and delimiting I and not-I, and as being continuous in time and over history.

Viewing psychological annihilation in the context of an intersubjective field means that this experience is interpreted as occurring within a living system of mutual influence. The visible manifestations of the experience are therefore not seen to emanate from a pathological condition localized solely within the patient; nor, however, are they regarded simply as reactions to a primary victimization at the hands of others. Such unilateral conceptions, emphasizing an exclusive determination either from the side of the patient or from the side of the human environment, fails to take into account the complex transactional process occurring between the two. Sometimes persons undergoing the experiences described here are viewed as carrying a special vulnerability or even predisposition that is then seen as a determinative factor in the genesis of personal annihilation. The problem with such an idea is that it represents a return to Cartesian and objectivist thinking, within which factors somehow located "inside" an individual—in his or her mind or brain—become operative causes in the unfolding of subjective states. We then have a picture of an isolated mind, containing predisposing sensitivities and vulnerabilities, which collapses in the face of objective external pressures of some kind. In an intersubjective framework of understanding, there are no fully isolable vulnerabilities that exist inside anyone, because what appears or does not appear as a vulnerability only materializes within specific intersubjective fields.

Imagine a patient who feels she is not present, does not exist, and has no self. Imagine further that someone not familiar with such states asks her, "How are you today?" The use of the second-person pronoun "you" implies to the patient a degree of existence she does not experience, and a gulf of misunderstanding and invalidation opens up between her and the questioner. Perhaps the patient gives the answer, "A billion light years," expressing how far away she feels from the questioner in view of the naive assumption having been made that there is a "you" to whom the inquiry would be intelligible, a "you" that could report on how it feels at the time. Perhaps the patient also experiences an invasion and usurpation by the questioner's unfounded assumptions, and she begins to speak of a machine sending rays into the center of her brain, to give this deepening annihilation experience form and substance. From the standpoint of the questioner, one who takes a Cartesian view of things, the patient's replies are utterly incomprehensible. The question, after all, has been appropriate and clearly phrased, and the answers coming back are without apparent connection to all that is true and real. The patient is at most a few feet away rather than a billion light years away, and there is no machine in the world that can perform as the patient has now begun to claim. Clearly, he thinks, this patient's sensitivities and vulnerabilities are such that the slightest human interaction triggers bizarre reactions stemming from pathological processes taking place inside the patient's mind, body, or both. A reciprocally reinforcing intersubjective disjunction has thus arisen in which the questioner ascribes defects to the patient's mind and brain even as the patient experiences her mind and brain as being penetrated and inhabited by a foreign influence.

Now imagine a second individual who speaks to the patient differently, who finds a way to acknowledge her sense of nonbeing and who understands as well the patient's readiness to surrender herself to whatever is attributed to her. He speaks to the patient in the third person, conveys his knowledge of how terrible it is not to exist, and in a variety of highly concrete ways lets the patient know she is not alone in the catastrophe that is the ongoing situation of her life. The patient, surprised by this different approach, actually begins to feel understood and, paradoxically, begins also to feel a flickering of her own existence, moments of directly sensed being alternating with the continuing feeling of nonexistence or nonbeing. These moments of being, occurring because of the validating experience of being seen and acknowledged, have a painful aliveness about them, draniatically contrasting with the numbness and deadness accompanying the sense of nonexistence. Perhaps the patient, after a period, says she has been stung by a swarm of bees, concretizing the sporadically recurring moments of aliveness as they alternate with episodes of the familiar deadness and nonbeing. Let us imagine further that this second person perceives the metaphor of this transitory delusion as well and finds ways to address the ambivalent experience the patient is having of coming back to life. Her sense of existing thus becomes strengthened again, by the incomparable power of human recognition. The patient's readiness to surrender to others' attributions and definitions, itself embedded in a complex, lifelong history of intersubjective transactions, is not engaged in the foreground of this second interaction and therefore does not appear as an operative defect or vulnerability in the experiences that unfold. This is because the intersubjective field in this instance is characterized on the one side by gradually developing understanding and on the other by a predominance of validation and an increasing sense of being.

In the example cited, we see how a clinician operating on Cartesian assumptions is not in a position to understand experiences of nonbeing. To such an observer, it is simply not true that the patient does not exist, it is not true that she is absent, and her claims about penetrating rays from influencing machines appear extravagantly delusional. Any reaction on the part of the clinician communicating this view, of course, intensifies the patient's experience of invalidation and annihilation, giving rise to a spiraling of disjunctive worlds in which the patient elaborates ever more concretized images of her obliteration and the clinician becomes ever more appalled by the spectacle of madness unfolding before his eyes. The patient's so-called delusions, in the context of this vicious spiral, emerge as expressions of subjectivity under siege, products of a war of the worlds constituted by mutual misunderstanding and mutual invalidation.

To further define and illustrate the context of personal annihilation, let us consider another patient, a young Catholic woman who for years had been preoccupied with visions of herself as having a special connection to God. In vivid hallucinations and elaborate delusions, she experienced a oneness with God the Father and God the Son, variously identifying with the Holy Virgin, the Holy Ghost, and Jesus Christ Himself. Claiming at times to have undergone sexual union with Jesus, to have physically flown to Rome to be held in the arms of the Pope, and to be channeling God's healing, peacemaking powers to the entire human race, this patient's ideas and beliefs were such that those around her could not relate their own experiences to hers in meaningful dialogue. Accordingly, the patient was said to have lost contact with the real and to be psychotic. Phenomenologically, of course, no such judgment or diagnosis occurs, as one seeks instead to understand the patient in her own subjective terms, exploring the history of events that could make her situation humanly intelligible. This inquiry disclosed a pivotal incident in the patient's middle childhood years, the sudden suicide of her beloved father following devastating personal disappointments and failures in his professional life. It was discovered as well that the death was covered over by the family, falsely redefined as having been accidental, and then hidden away behind a wall of impenetrable silence. The affairs of the family thus continued as though the father's suicide had never occurred, so little being said of him that he was relegated to the effective status of someone who had never been. It was the family's turning away from the father's death and life that was the context of a gradually deepening sense of inner deadness and isolation in the years that followed. This was also the setting for her first ruminations on the figure of Jesus Christ and a special place she imagined for herself in the Holy Trinity. Over a period of more than a decade, secret religious thoughts about her relation to God gradually blossomed into full-fledged delusional realities, finally bursting forth in the family with great violence and precipitating the first of many psychiatric hospitalizations. Central in the patient's expressions at this time were loud, imperious demands that she immediately be united with Jesus, who she believed had been miraculously reincarnated in a church-affiliated counselor she had once known and depended on for a brief period.

The bond to the father, something that centrally sustained this patient as a young girl, had been lost when he died. Compounding this loss, however, his death occurred as an intentional suicide, which was unthinkable if, as she had believed during her early years, he actually loved her. Her unbearable experience of having been deserted by him, however, had itself been suppressed by the family's denial, so that the reality of all she had known with him when he was alive and all she had felt on losing him when he killed himself was undercut and nullified, eventually undermining her very selfhood as the feelings of deadness expanded and deepened. How is one to understand this patient's seemingly fantastic religious claims and demands, in view of this context of abandonment and personal devastation? The Cartesian analyst, following Freud, inevitably focuses on the wide disparity between the patient's beliefs and the purportedly objective truth of her life situation, perceiving a deficiency in reality testing, a break with the objectively real and the setting up of an idealized alternative in its place. The streaming religious fantasies and delusions, from such a viewpoint, appear as wish-fulfilling substitutes for the lost connection to the father, and the patient's disturbance seems to consist precisely in her immersion in these fantasies at the expense of attention to her actual, painfully sad situation. An intersubjective analysis, by contrast, focuses on how the patient's so-called delusions protect and preserve a shattered world, how they reinstate a personal reality that has been substantially annihilated, how they embody an effort to resurrect a world-sustaining tie in the midst of an experience of complete obliteration. Far from expressing a flight from painful reality, according to this post-Cartesian view, she is understood to have used the symbols of her faith to encapsulate a remnant of the destroyed bond to her father and thereby to maintain a hold on all that was most real in her experience of herself and her world. The patient's demands to be united with Jesus Christ, urgently and aggressively reiterated in the early course of her treatment, were thus cries for the world-preserving connection on which her very existence depended.

Viewing a person such as this as delusional highlights the disparity between her experiences and beliefs and the conditions of supposed external reality. From this perspective, a goal inevitably materializes to bring the patient's ideas into conformity with all that is generally agreed on as real and true. These normative beliefs have no place for special linkages to Jesus Christ and unassisted flights to Rome, such ideas being seen as pathological fantasies that need to be interpreted, relinquished, or suppressed. What, one may ask, is the effect on the patient of being seen and treated in this way? Such a view inevitably communicates a message that the patient's most urgently felt desires are misguided and that her sole remaining hopes for restoring herself and her reality are without foundation. This message repeats and reinforces the emotional abandonment and invalidation she experienced at the hands of her father and her family, and its effect is to accelerate the delusional process as the patient seeks her own survival in ever more concrete, vividly dramatized ways. A vicious spiral has thus again sprung into being, in which disjunctive worlds war with one another in unending cycles of misunderstanding and reciprocal invalidation.

An analyst who understands the meaning of this patient's cries, by contrast, comes to her with no agenda to realign the content of her experiences; his purpose is rather to introduce a new element into her devastated life, one around which she can refind the felt core of her existence. This element will be embodied in her experience of him and his understanding, something with a powerful emotional impact, calming and reassuring in its effect. This analyst will establish his presence, at first physically in space and time, by regularly appearing and reappearing, and by engaging- the patient's attention through concrete, simple interactions of various kinds. When eventually the full force of her delusional efforts to salvage herself and her world become directed toward him, as inevitably they will, and she pressures him to reunite her with the man she believes to be Jesus Christ, he will respond gently but definitively by telling her that there is only one person in the world she should be concerned about seeing, and that he is himself that person. He will explain further that there are to be no meetings with anyone except for those that he and she have with each other, for it is in their work together that she will become well again and return home to be with those who love her. In all of these interventions, the analyst is guided by an understanding that he must himself become the inheritor of the patient's strivings and that his relationship to the patient is the central battleground on which her psychological survival is to be worked out. How does she respond to all of these things? The delusional process, far from being exacerbated, actually begins to recede as the analyst is established as someone in relation to whom she can recover a sense of herself and of the reality of her destroyed world. At first, her dependence is extreme, and she even intimates that her newfound therapist might indeed himself have some special status with respect to God Almighty. Such expressions are understood as reflecting the power of the bond that is forming, a bond that undergirds a shattered universe in the process of being reassembled. The analyst accordingly gives no response to such attributions on the level of their literal content and occupies himself instead with reinforcing the developing connection she has begun to experience between them. Each step in the solidification of their tie is accompanied by a further stabilization of her world and a continuing decentralizing of her religious images as their function passes over onto the therapeutic relationship. In the early stages of this healing process, any disturbance in the tie that has been evolving produces extreme reactions of terror of abandonment, and sometimes also a resurgence of the religious fantasies. As the threatened tie is reinstated in each instance, the terror disappears and the religious imagery recedes. In this way, the conditions are gradually established within which her experiences of abandonment, betrayal, and invalidation can begin to be addressed and healed on a lasting foundation.

Once a post-Cartesian attitude toward the psychoses is adopted, as the two cases described here illustrate, new understandings crystallize and previously unseen opportunities for therapeutic intervention appear. Let us continue to pursue the implications of this shift in perspective by discussing two other important issues in clinical psychoanalysis to which an understanding of annihilation states is centrally relevant: the problem of mania and the nature of psychological trauma in its most extreme forms.


3. Terms such as agency, authenticity, cohesion, and others are used here in an exclusively phenomenological sense, referring to dimensions of self-experience along which annihilation states typically take form (Orange, Atwood, & Stolorow, 1997, chapter 4).
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