I have long felt that psychosis is more adequately understood when it is seen as the most extreme form of dissociation - a need so intense that it is not the body, or emotions, or memories that are dissociated, it is reality itself.
Although it is reality that is dissociated (through delusions, hallucinations, paranoia, and cognitive distortions), it is fundamentally the emotions that are most important in making sense of the psychotic features and in bringing the client back. I have no doubt that meds are important for some, but not everyone benefits from the psychological numbing effects of the atypical antipsychotics.
What my clients have taught me is that the key to recover is to reclaim the body, and with it the emotions that are so painful the person needed to create a different reality, where the client is often a different person, with different origins, and who is much more important in some ways than they ever were in their "normal" life.
This is a free article (until the end of December) from the International Forum of Psychoanalysis in which Lawrence Kirshner offers a psychoanalytic take on psychosis and its roots in trauma (follow the links to read online or download).
Kirshner, L.A. (2013, Jun 4). Trauma and psychosis: A review and framework for psychoanalytic
understanding. International Forum of Psychoanalysis, DOI: 10.1080/0803706X.2013.778422
Lewis A. Kirshner
- Published online: 04 Jun 2013Abstract
Empirical research substantiates Ferenczi's conception of the etiological importance of early neglect and abuse in the development of psychosis. Abuse can derail the development of language, identity, and social relationships that are intrinsic to schizophrenia, possibly through undermining secure attachment relationships. The Lacanian emphasis on language and early proto-dialogues with the Other can be useful in understanding this process. Some therapeutic implications for psychoanalytic approaches to the treatment of psychosis are proposed.
Here is a bit from a section further down in the article.
Development of language, the symbolic, and attachmentTo understand how trauma and neglect may result in schizophrenic disorders, we need to connect the typical deficits and symptoms of psychosis with developmental processes. The importance of access to language seems a promising avenue, as positive symptoms in schizophrenia are only identified and reported as speech or thoughts, and the ability to use relationships with others to modulate traumatic experience or to act as a barrier to it depends on the use of semiotic functions. Within psychoanalysis, Lacan was perhaps the most important theorist to hypothesize an inability to use language as the source of psychotic symptoms, notably as the basis for hallucinations and delusions, which are language-dependent entities (see Sauvagnat, 2003, and Vanheule, 2011, for discussions of this model). Of course, the concept of a thought disorder (in fact, a speech disorder) has been a basic feature of schizophrenia since Bleuler's work, and, recalling Crow's hypotheses, subjectivity depending on speech may be our key species characteristic, closely related to important developmental concepts such as theory of mind and intersubjectivity that have also been linked to schizophrenia (Lysaker, Outcault, & Ringer, 2010).
And this is from a later section.
Treatment issuesResearch by Karon and Bos (cited in Ver Eecke, 2003) found that experienced clinicians were more successful with schizophrenic inpatients, especially over longer time periods. One explanation for this result may be the greater ability of experienced therapists to build a relationship with psychotic patients, which can take a long time. In general psychiatry, there is a growing recognition that individually designed approaches to treatment can be quite helpful (Mojtibai et al., 1998; Shean, 2009), suggesting the uniqueness of each therapeutic couple's construction of basic communication links. The difficulty of building alliance and trust with psychotic subjects has been emphasized by many psychoanalytic practitioners and suggests why the application of classic forms of analytic treatment may be misguided.The focus of psychoanalysis on the individual subject, however, does provide the cornerstone of a psychotherapeutic approach, although the techniques of treatment may be far from traditional models (e.g., Abensour, 2008; Benedetti, 2011; Lucas, 2009). The psychotic is a person, a subject like anyone, but his subjectivity may take unusual and cryptic forms that can discourage clinicians from pursuing a treatment relationship. Lacan (1993) wrote in a late seminar about helping psychotics to ground their subjectivity through creative processes, making something new that establishes their identity through an object. In a similar approach, Abensour (2011) described how creative writing served as a kind of anchor in reality for many of her patients who suffered from the dilemma of a floating self, disconnected from the body, a past history, and relationships with others. Creative products acquire a real existence in time (like the transitional object) that can confirm the continuity of the subject and express its inner states.