Psychosis, Trauma, and Ordinary Mental Life
Publication: American Journal of Psychotherapy
Abstract
Psychotherapy has gained wide acceptance as a primary treatment for non-psychotic psychological disorders but has yet to find the same acceptance in the treatment of psychosis. One reason for this is the idea that schizophrenia is a genetically determined brain disease unlikely to respond to psychological treatments. A second reason is the difficulty most people have in relating the symptoms of psychosis such as hallucinations and delusions to their own mental processes. This paper relates the manifestations of psychosis to ordinary mental life, and describes how psychotic symptoms arise as meaningful expressions of unbearable psychological pain in the aftermath of adverse life events.
Psychotherapy has gained wide acceptance as a primary treatment for non-psychotic psychological disorders but has yet to find the same acceptance in the treatment of psychosis. One reason for this is the stubborn persistence of the idea that schizophrenia is, in essence, a genetically determined brain disease unlikely to respond to psychological treatments. A second reason for the low profile of psychotherapy for psychosis is the difficulty most people have in relating the unusual symptoms of psychosis to their own experience and ordinary mental life. Clinicians and the general public can readily accept that psychotherapy helps patients with non-psychotic depression and anxiety because they know from personal experience that talking things through with the right person can relieve distress, but when they see little connection between ordinary mental life and psychotic symptoms, the utility of talk therapy for psychosis may not be intuitively obvious.
A particular challenge in grasping the psychology of psychosis requires the clinician to empathize with levels of anguish not often encountered in everyday life. A person who does not experience psychosis, but who has suffered significant adverse events in life may take a week off from work, or take a temporary leave of absence, or temporarily withdraw from social interactions, all the while maintaining the hope and expectation of returning to the life he or she has previously known. It can be difficult even for psychologically minded readers to imagine what level of pain would be required for them to give up everything that they hold ordinary and dear, including their job, interpersonal relationships, hope for the future, prior sense of the past, and their previous personal identity. What kind of psychological pain would prompt that kind of letting go that psychosis demands? Although psychosis is not, strictly speaking, a voluntary choice, individuals who have recovered from psychosis sometimes describe a wish to remain “crazy” rather than return to the pains of the real world. When the anguish of living is so great that individuals can barely cling to their sanity, they may at some point let go of their hold on reality and be swept along in the torrent of psychotic events.
For example, one patient, Tanya, an inner-city teenager struggling to stay in school, had been raped repeatedly by her father. Occasionally, she surrendered to an interior “voice” named “China.” Unlike Tanya, China was brash, decisive, and immune to being hurt. As the patient put it, “When I am getting tired sometimes it is easier when China comes, because China doesn’t care what anyone thinks, because Tanya is too caring. Forget about it. Let China deal with it. I don’t want to deal with it. And that is how it can go.”
Frieda Fromm-Reichmann helped her patient Joanne Greenberg to abandon the delusional world of Yr she had created, and to live in the real world with all its pains and disappointments (Greenberg, 1964). To Joanne’s complaints about the difficulties of reality, Fromm-Reichmann remarked, “I never promised you a rose garden”—thereby providing the title for Greenberg’s book.
This paper will relate the seemingly bizarre manifestations of psychosis to ordinary mental life and describe how psychotic symptoms can be understood to be a psychological consequence of adverse life events. The paper is about why we should have a natural expectation that psychotherapy can help individuals with psychosis. To sustain a psychotherapeutic ambition for patients with psychosis, clinicians require an understanding of the psychology of psychosis. Clinicians lose psychotherapeutic ambition when conditions elude empathic understanding, and they give categorical diagnostic labels, such as “schizophrenia,” and speak of patients having a disease. This language of having something rather than being a certain way suggests that a disease element separate and apart from the essential nature of the person has taken possession of the individual, as opposed to the symptoms being an expression of the person’s essential nature. Any psychotherapeutic technique for treating psychosis must be based on a psychological understanding of the psychotic process. The more easily the therapist connects psychotic experiences with ordinary mental life, the more experience-near the patient becomes, and the more the treatment can proceed in keeping with the general understanding of human psychology and well-established principles of psychotherapy.
All psychodynamic theories of the psychology of psychosis regard psychotic symptoms as the intrusion into adult mental life of primitive (developmentally early) psychological processes that are normal in childhood. The description to follow will draw heavily on psychoanalytic object relations theory as conceived by Melanie Klein (1935, 1946). It is hoped that this paper will be of interest to clinicians less familiar with the ideas of Klein than with those of other analysts who have written about psychosis, and to clinicians early in their career with a desire to work psychotherapeutically with individuals with psychosis.
In brief, the psychological model of psychosis described here is organized around the idea that the symptoms of psychosis are a meaningful expression of the mental life of a person with psychosis, much in the way a play is a meaningful expression of the playwright’s life experience. This comparison between a play and a delusion is intended to be more than an illustrative metaphor to help make a point. A play and a delusion are both creative works of fiction that express human concerns in the form of a story in which a variety of characters interact. Psychosis is a very particular kind of theater of the mind made possible by the re-emergence of psychological processes normally occurring in childhood. It is the way that young children think and feel, which usually fades into the background of mental life by the time the child is between eight to ten years old. In psychosis the mental play is produced from a script based on the psychotic person’s phantasy life. (The spelling “phantasy” is used as Klein used it, to distinguish primitive unconscious phantasy from the fantasies that appear in the wishful thinking of daydreams.) Primitive unconscious internal object relations, brought to the foreground of consciousness by adverse life events, provide the cast of characters and the story line for the play. Concrete thinking and the erosion of the biological substrates that maintain boundaries between thoughts, feelings and perceptions stage the play in the theater of the real world. Logical reasoning applied to anomalous subjective experiences that arise during the psychosis contributes to the play’s having a long, tragic run. In the body of the paper I will attempt to bring an expanded commonsense understanding to this condensed psychoanalytic conception.
The Primal Split in the Psyche and Primitive Internal Object Relations
Jean Piaget (1977), Daniel Stern (1985), and Melanie Klein (1935, 1946) offer overlapping descriptions of early childhood development, each with a different focus. Stern places the development of the self within Piaget’s sensori-motor period (birth to the acquisition of language), and divides the evolution of the self into four phases:
1)
emergent self that begins to organize experience from birth to two months,
2)
core self that has a sense of agency and affectivity across time (two to eight months),
3)
subjective self that understands “my subjective experience is my experience alone” (eight to 15 months), and
4)
verbal self (15 months and beyond) that knows it is the central actor in a personal life narrative.
Klein, based on her observations of young children and her psychoanalytic work with both young children and adults in regressed states of mind, described the mental processes she saw operating in what Stern would call decades later the “emergent” and “core self” periods. This paper will link the psychological processes that occur in psychosis with mental events that occur as a matter of normal course in the mental life of young children.
The model to be presented begins with Klein’s description of a primal split of the psyche in the preverbal first two years of life into a good self in relationship to a bad object. This split populates the mind with a primal protagonist and a primal antagonist whose interactions are elaborated in the form of primitive, internal object-related phantasies in which the self is imagined doing something to a psychological object or the object is imagined doing something to the self. The activity that children first imagine passing between self and psychological object is colored by the oral and anal themes of early childhood and the intense emotions that accompany these concerns. Before the acquisition of language, these primitive internal object-related phantasies are embedded in sensory images infused with intense affect, i.e., very young children think in images rather than sentences. After the acquisition of language, these primitive internal object relations find expression in fairy tales and children’s books in which the child can identify with the protagonist and the antagonist in the story. Ordinarily, these primitive phantasies fade from consciousness by age eight to 10 years. Later in life a failure to achieve social competence or adverse life events (Longden & Read, 2015) resonate with primitive unconscious phantasies, which are linked to the onset of psychosis. Without realizing the connection, an individual on the verge of psychosis begins to feel that the events occurring in day-to-day life are quite like those imagined in primitive internal object-relations phantasies.
At birth the infant leaves the relatively protected quiet of the womb for a world of bright lights, loud noises, and other tactile sensations. The infant organizes this rapidly shifting collage of sights, sounds, and body sensations by gradually linking visual, auditory, and tactile sensations into mental representations of the self and the outside world; e.g., the “hand” that I see is the same hand that I feel when I grasp an object. It is “my” hand. Thinking at this stage of development consists of affectively charged images rather than verbal thought. Experiences fall into two basic categories, those that are pleasurable and those that are distressing. According to Klein, to reduce painful psychic tensions, the mind undergoes a psychological split in which the primitive self preferentially identifies with positive experiences while attributing painful experiences to the world outside the psychological boundary of the self (Riviere, 1936). In this split, the self preserves hope of relief from pain by imagining the self to be pain free in its natural pristine state, while attributing painful states to the intentional actions of bad persecutory objects outside the self that intrude upon this pristine, blissful state. In this notion, when the quiescent infant begins to feel hungry, it does not experience hunger pangs as arising from within the self, but rather as the painful intrusion by an outside agent into the pristinely peaceful, hunger-free self; i.e., a persecutory agent is doing something to the self to cause pain. The bad object is said to be “persecutory” because in this primitive stratum of the mind, mental pain occurs because the persecutory object intends to cause pain. In this mental world, mental distress is never accidental. It is always intended, with malice.
Residuals of this persecutory mental structure present in childhood are common in adult mental life, for example, saying “my head is killing me,” when one has a headache. This sentence implies an imagined interaction between two characters, a persecutory “head” that is doing the killing, and a “me” that is a victim of the “head.” In fact, when a person has a headache, there is no part of the body more apparently part of the person than the head, but the headache sufferer’s mind has been split psychologically into two parts, a “me” that is feeling the pain and a persecutory object that is inflicting the pain upon the self. A moment’s reflection on the seemingly peculiar grammar of this sentence reveals the unconscious phantasy that headaches do not arise from within the self but rather from the action of a persecutory agent (the “head”) that intrudes upon what would otherwise be a perfect pain free self. This split of the mind into a perfectly good, pain-free self and an entirely bad persecutory object is the psychological foundation of paranoid psychosis. In this split, disavowed elements of the self go missing from the person’s subjective experience of the self and reappear in consciousness projected into mental representations of people and things outside the boundary of the self. Instead of emotional angst that is experienced as one’s own thoughts and feelings, connected to one’s real life, the person with psychosis transforms intra-psychic anguish into an interpersonal problem, a problem between the self and a persecutory object whose activities are inflicting pain on the self. Individuals with psychosis locate their problem in the outside world rather than within their own psychology, in the form of a variety of familiar persecutors, for example, a neighbor believed to be putting poison gas under their doors, or an organization such as the Mafia, the FBI or the CIA thought to be spying on them.
Persecutory objects abound in our psychology and surround us in daily life in personal relationships, work, myth, religion, and history. For example, the serpent is the persecutory object in the Garden of Eden. The innocent bliss of the Garden of Eden represents the perfect, pristine, pain-free condition of the primal self. As the story goes, everything would have been great were it not for the serpent’s intrusion. Good people everywhere can close ranks against the serpent and the Devil, reassured that evil will arise outside the boundary of the self rather than from within. At the level of personal individualized myth, some people regard their boss or their spouse (for brief or extended periods of time) as the bane of their existence, in whose absence their talents and happiness would, in their estimation, certainly flourish. And so it goes in the cavalcade of persecutory objects that have carried the projected fears and dissatisfactions of human beings throughout history.
Primitive Internal Object Relations and Narrative Stories
In Klein’s view, the self and its persecutory objects constitute a fundamental paradigm. The primal structure of the human mind from early childhood into adult life is object-related; i.e., the self exists in affectively charged psychological relationships with a variety of internal objects. In those relationships, the self is imagined doing something to an object, or the object is imagined doing something to the self. What young children imagine to be going on between the self and the object is colored by the intense affects and body processes associated with drive states that characterize the early years of life. These primitive self-object dyads find expression first in pre-verbal images, then later in verbal phantasies and narratives, as in fairy tales. Consider an example of the pre-verbal expression of primitive object related phantasies provided by Susan Isaacs in her seminal paper “The Nature and Function of Phantasy” (Isaacs, 1948):
A little girl of one year and eight months, with poor speech development, saw a shoe of her mother’s from which the sole had come loose and was flapping about. The child was horrified, and screened with terror, for about a week she would shrink away and scream if he saw her mother wearing any shoes at all, and for some time can only tolerate her mother’s wearing a pair of brightly colored house shoes. The particular offending pair was not worn for several months. The child gradually forgot about the terror, and let her mother wear any sort of shoes. At two years and 11 months, however (15 months later), she suddenly said to her mother in a frightened voice, “Where are Mummy’s broken shoes?” Her mother hastily said, fearing another screaming attack, that she had sent them away, and the child then commented: “They might have eaten me right up.” The flapping shoe was seen by the child as a threatening mouth, and responded to as such, at one year and eight months, even though the fantasy could not be put into words. Here, then, we have the clearest possible evidence of the fantasy can be felt, and felt is real, long before it can be expressed in words (p. 85).
As in the example above, in the first years of life, the child’s conception of the world is dominated by projected elements of its own mind; e.g., the child’s projected oral aggression becomes a dangerous mouth that takes the form of a shoe.
Fonagy and Target (1996) distinguish two modes of cognitive functioning in young children, an early stage of psychic equivalence, in which whatever is psychically experienced is felt to be real, and the pretend mode, in which ideas represent the objective world, but their correspondence with reality is intermittently and voluntarily ignored, allowing children to play at pretend games. In the “psychic equivalence” mode, what children feel is experienced as being real. The girl who was frightened of the shoe was not telling her mother “The flapping sole on your shoe bears an uncanny resemblance to a mouth opening and closing.” Rather, she saw the shoe as a threatening mouth, and reacted with the intense fearful emotion appropriate to her perception. This predilection to experience what is felt as being real is suppressed in the course of normal development as the child acquires more realistic images of the world and moves into the “pretend mode,” but this way of experiencing the world reemerges in psychosis. The “pretend mode” allows children (and adults) to regulate psychic tensions by identifying with and playing at being fictional characters. For a time we “pretend” that our identity is someone other than who we really are. For example, an imaginative four year old announces she is the ringmaster of a marvelous circus in which “Strong men are doing strong things!” and the adults happily play along. Later in life, the “pretend mode” allows construction of figurative verbal metaphors in which we say that one thing is like another without losing sight of the fact that the two things being compared are not identical. Just as every adult knows, you do not remind a small child flourishing his cape that he is in fact not Superman. When we hear of there being “an ocean of grief” at a memorial service, we do not express our sympathy over everyone having gotten wet. Mental health maintains a balance between the play of imagination and our more objective conceptions of the real world.
The primitive object-related phantasies that predominate in the first three years of life and the narratives they generate often have oral and anal themes, in keeping with the concerns of young children,. These early primitive phantasies shape the development of the mental representation of the self. For example, the child’s experience of eating becomes the body-based template for the psychological processes of introjection and identification, which allow aspects of the environment to be experienced as part of the self. Defecating becomes the body-based template for projection, which allows aspects of the self to be extruded from the self-representation and deposited in mental representations outside the self. Human beings are forever taking in and pushing out physical and mental content.
With the acquisition of language, words are available to express primitive object-related phantasies in child’s play and in fairy tales. Recall the child who was frightened that her mother’s shoe would eat her. Cast in object-related terms, young children often phantasize about biting or eating the object, or being bitten or eaten by the object. The minds of young children teem with dangerous oral objects that are projections of the child’s oral sadistic phantasies, such as ravenous shoes or the potty that may swallow the child when it is flushed. Frightening oral themes of this sort appear in fairy tales and psychotic delusions alike. For example, in “Hansel and Gretel,” a famine descends upon the land, and a terrible mother plans to leave her two children to die so that she can conserve the limited food supplies for herself. The oral enticement of a delicious gingerbread house lures the children into bondage with a cannibal witch, and they narrowly escape being eaten. In “Little Red Riding Hood,” a wolf eats Little Red’s grandmother, then the wolf takes on her grandmother’s form. In so doing the persecutory object hides inside the good object. This deceives Little Red, and the wolf eats her as well. Fortunately, a passing woodcutter chops the wolf open and liberates the grandmother and her grandchild from the wolf’s stomach. In this story, in primitive object-related terms the good mother and the self (the grandmother and Little Red) are temporarily trapped inside the bad object. The self and its good objects remain whole and intact until they are saved by the woodcutter, who chops open the bad object and liberates the good objects trapped inside. The proverbial “wolf in sheep’s clothing” expresses the objected-related phantasy that a bad object can be hidden inside a good object.
The characters in fairy tales, children’s books, and comic books are like the characters that appear in psychotic delusions. They are generally of the “perfectly good” or “perfectly bad” type. For example, the Superman the child plays at being is all good and all powerful. He doesn’t cheat on his taxes. Lex Luther is all bad. He doesn’t spend weekends volunteering at a soup kitchen for the homeless. The paranoid patient who believes that the neighbor he believes is trying to poison him does not remark in passing that this same neighbor has a kind side that shows in his love of animals. The child and the delusional person know which characters are “good objects” and which are “persecutory objects.” There is no mixture of good and bad to integrate. There is one fly in the ointment of Superman’s seemingly perfect world—kryptonite. Kryptonite is the only persecutory bad object with the power to enter Superman and bring him down. In keeping with Klein’s formulation that primal dangers derive from a persecutory object outside the self, Superman and his admirers need not fear that weakness will ever arise from within the Superman self.
In secure, empathic family environments, the primitive unconscious phantasies of early childhood fade, and are replaced by more enduringly positive and realistic socially validated images of the self and others. But when the family environment does not support the emergence of the child’s authentic self, these primitive phantasies do not fade. Cumulative social disappointments within the family or care takers seen as doing painful things to the self, reinforce primitive conscious and unconscious object-related phantasies in which the self is a source of pain rather than joy to the people around it (Karon, 1981, 2003). Like a massive, deep, unseen rock formation in the ocean that creates ripples in the currents of development that flow over it, these primitive object-related phantasies shape the child’s relationships with others without being literally enacted in their primal terms. Then, as if an earthquake lifted the hidden ocean floor above the surface of the water, in adult psychosis this latent object-related formation is thrust starkly into conscious view, dominating the psychotic person’s conception of the self and the world.
Consider how the primitive unconscious object-related phantasies that find expression in fairy tales reemerge in adult psychosis. A male patient with psychosis, who came from a chaotic family, suffered from a delusion shaped by primitive oral phantasies. He reported that he had developed a cancer when, at birth, his mother touched his penis. He believed that this cancer now coated all his internal organs. Parsed in object-related terms, a persecutory “bad mother” injected her cancerous spawn across the boundary of the self through the conduit of his penis. The persecutory object (the cancer) threatened to swallow his internal organs (the self), much as the wolf swallowed Little Red Riding Hood. Because he feared that medication would disturb the delicate balance between his organs and the cancer, he refused all pharmacological treatment. He imagined that taking medication would weaken his resistance to the encroaching persecutory object, his personal “kryptonite.” This man was frozen in a state of terrifying “annihilation anxiety,” in which he feared his mind was about to dissolve. His delusion is a horrifying version of “Hansel and Gretel” and “Little Red Riding Hood” with no happy ending, a personal fairy tale with a readership of one.
Consider next a 30-year-old man with two prior psychotic episodes who reported in a first psychiatric consultation an intense anxiety he associated with his belief that a terrible drought was about to occur, which led him to fill his apartment with many jugs of stockpiled water. At the end of the consultation, the patient said, “Can I ask you some questions?” The patient asked how old the therapist was, if he was married, did he have children, and where did he live? Before offering any answer the therapist stated, “I am wondering why it is important for you to know the answer to these particular questions.” The patient responded in a matter-of-fact tone as though the reason were perfectly obvious. “If I am to model myself after you, I must know everything about you! I must know details.”
In the transference, he imagined his relationship with the therapist as equivalent to his swallowing the therapist whole; i.e., indiscriminately absorbing attributes of the therapist’s identity into himself. Before swallowing the therapist and taking on his identity, the patient sought to determine in detail what the therapist was made of, so as not to inadvertently ingest a toxic persecutor disguised as a wolf in a therapist’s clothing. Experience teaches that if you want to swallow a person who looks like a kindly grandmother, you’d best first determine whether there is a wolf lurking inside. His delusion of an impending draught reflects his underlying primitive phantasy of being deprived of essential oral supplies, akin to the famine in Hansel and Gretel fairy tale.
In summary, the primal mind splits into the pristine self and the persecutory object. This populates the mind with a primal protagonist and a primal antagonist whose interactions are elaborated in primitive internal object-related phantasies in which the self is imagined doing something to a psychological object or the object is imagined doing something to the self. These interactions form the basic story line that is elaborated in the delusional productions of individuals with psychosis.
The Breakdown of Distinctions and Boundaries in Psychosis
Having outlined the relationship of paranoid delusions to primitive internal object relations, we now turn to a second issue of importance in relating psychosis to ordinary mental life: the difficulty individuals with psychosis have in maintaining clear distinctions between mental representations of different things and upholding boundaries between subjectively different experiences. When individuals with psychosis express themselves in concrete metaphors rather than figurative metaphors, and when the “ego boundary” breaks down (Federn, 1952), there is difficulty distinguishing among thoughts, feelings, and perceptions.
Concrete Metaphor
Imagine a mother who has just learned that her child has been mistreated at school. This mother says, “They don’t know who they are dealing with. I can be like a bear when it comes to defending my daughter.” The meaning of this figurative metaphor is clear. She will defend her child with the same determination with which a mother bear would defend her cubs. This metaphor is apt because human beings can easily identify with the family group of a mother bear and her cubs. Teddy bears are the lovable children of the animal world. Maternal ferocity is signified by the bear’s size, strength, biting mouth, and tearing claws. The bear’s threat is an oral aggressive one that resonates with primitive internal object relations in which the child fears being bitten by sharp teeth and swallowed by a bad object. This mother’s metaphor warns, “If you endanger my children you are at risk of being torn apart and eaten.” Figurative metaphor points to a similarity between two things while simultaneously maintaining an awareness of the essential differences between the two things being compared. This mother is saying she is in a certain context like a bear, but she maintains a clear distinction between herself and a bear.
Imagine a psychotic version of the above story. A mother fails to defend her child against a grievous injury that she believes she could have prevented. She feels intense guilt, and her image of herself as a good mother shatters. She is distraught and full of rage at herself and the circumstance that injured her child. After a sleepless night she goes to a nearby emergency room and asks that her hands be x-rayed because during the night she had the distinct feeling that claws were growing in the palms of her hands. When asked her name, she replies cryptically, “Ursa.” She is expressing her thoughts and feelings in the form of a concrete metaphor of the type often seen in psychosis, in which she is a bear rather than like a bear. Thinking in concrete metaphors leads individuals with psychosis to equate their identity and the identities of other people with characters in primitive object related phantasies. She is given a diagnosis of psychosis and admitted to the inpatient psychiatry unit. When she protests in an agitated manner that she must be released immediately because her child is in danger, she is medicated with haloperidol. She comes to believe that the hospital staff is in league with people who pose a danger to her and her daughter. Though too early to make this diagnosis, in morning rounds the treatment team begins to wonder whether this first psychotic break will lead to “schizophrenia.”
It will not be difficult for the psychodynamic clinician to intuit the meaning of her patient’s delusions. Unable to endure the agony of guilt, the patient lets herself drift away from the real world into a delusional play that is enacted in the theater of the physical world, a play that distorts her reality so that she can go on living. In the real world she failed to be a strong mother who could keep her child safe. In the delusional world she is a bear, in claw and name, a mother of the fiercest kind. She is not consciously aware that her identification with a bear is being expressed in her bodily feeling of claws growing in her palms, and her name reflecting the bear constellation “Ursa Major.” The concrete metaphor “I am a bear” insulates her from a painful array of thoughts, feelings, and memories associated with her failure to defend her daughter. These associations go missing from her awareness and reemerge, fixed and frozen in place in the seeming objective world where she is now engaged in a desperate struggle with forces that threaten her and her daughter. An intra-psychic agony has been transformed into an interpersonal problem. Her delusion is a complicated wish for a “do over” to deny what really happened and imagine a better outcome. Concrete metaphorical thinking freezes painful experiences into what the psychotic person believes to be a concrete reality. Located outside the self, it does not resonate with the painful memories and emotions associated with the psychotic person’s core conflicts. The psychotic person remains in pain about a problem he or she believes to be located in the outside world, but without the emotional resonance of figurative metaphor, the person cannot think effectively about the true developmental origins of this pain.
Ordinary and Concrete Metaphor
Conceptions of our minds, the minds of others, and the world are built largely upon body-based metaphors; experiences are understood in analogy to body processes (Klein, 1930; Isaacs, 1948). Over time, the infant’s interactions with the mother’s body are elaborated in body-based metaphors through which the child comes to know his own mental processes and the world. The brain is a sophisticated pattern-recognition machine wired to compare current stimuli with past stimuli, a capacity that allows for pattern recognition, symbol formation, and metaphor. When a child or an adult encounters some new mental or sensory experience, he or she tries to understand the new experience by relating it to something already known. We think, “This new experience is like something that I have already encountered.” We construct a metaphor. “This is like that.” “X is like Y.” By using experiences of one’s own body in relationship to the mother’s body, a child begins to comprehend the world. Anchored in body experiences, the child unrolls a marvelous chain of thousands of metaphorical links, where each “this is like that” connection extends the child’s mental reach, allowing it to knowingly gather the world in. For example, an early step in this process might be the jump from the mental representation of the breast to a rubber pacifier. The size, shape, and texture of the pacifier are similar to the good breast, which it comes to represent. Expanding outward into the world in a metaphorical chain with a myriad of oral links, the baby next finds a substitute for the breast in a bottle of baby formula with a rubber nipple, and from there on to homogenized baby food, and from there on to the “comfort foods” of adult life. Pass the mac and cheese and the mashed potatoes, please!
These sorts of metaphorical links that substitute one mental representation for another are the basis of symbol formation that allows for substitute gratifications and the diversion of dangerous impulses away from “good objects” toward “bad objects,” whereby the child can discharge aggressive impulses without endangering its “good objects.” In the admonition of childhood, “Step on a crack and break your mother’s back!” the possibility that the child could seriously injure the mother is acknowledged, but reassurance comes in the form of the simple phobic ritual of avoiding the crack. Psychologically speaking, the child’s aggressive impulses have gone missing from the child’s mind and have become physically located in the crack (projected into the child’s mental representation of the crack). By avoiding physical contact with the crack the child can avoid mental contact with dangerous impulses toward the mother. Our unconscious mental life is composed of memories and fantasies with an emotional valence that are linked through metaphorical connections to other memories and fantasies, in a chain of body-based metaphorical associations that expands over the course of development to constitute the human imagination and our mental representation of the world. We sing the world into being with the musical resonance of figurative body-based metaphor.
For example, when we say, “That is certainly food for thought!” we are describing the process of thinking about an idea as being like a good feed; i.e., an abstract mental process is like a body process. When we say, “I had to swallow my pride” we are describing a psychological process in a body-based metaphor. In this phrasing we mean to say, “I didn’t surrender to the other person. I didn’t completely let go of my pride. I temporarily hid my pride by swallowing it into an interior body space where it remained intact, from which it can safely re-emerge when the interpersonal coast is clear.” Recall how Little Red Riding Hood and her grandmother were swallowed by the wolf but remained intact in the wolf’s belly until it was safe to emerge. Recall Mother Ursa in the prior example, and how a bear’s teeth are like a wolf’s teeth. These images all derive from the same primitive internal objected-related world. When we say of an unfavorable life situation, “That really stinks!” we understand adversity as being like the smell of anal objects non grata that have been extruded from the self. A continuous developmental line extends in the use of body-based metaphor from childhood through fairy tales into the language and figurative metaphor of adulthood, which is then selectively fashioned into the concrete metaphor of psychosis.
In psychosis, the use of figurative metaphor goes tragically awry in a turn toward concrete thinking. We can assume from the evident terror of the child quoted by Isaacs that the child experienced the flapping sole of her mother’s shoe as a mouth, not as being like a mouth. This illustrates a characteristic of early mental life that Freud captured in his concept primary process, that Fonagy and Target (1996) call psychic equivalence, that forms the basis for what Segal called symbolic equations in psychosis (Segal, 1957), and that Arieti called paleologic (Arieti, 1974). In Segal’s words,
The early symbols, however, are not felt by the ego to be symbols or substitutes, but to be the original object itself. They are so different from symbols formed . . . that I think they deserve a name of their own . . . “symbolic equation.” (1957, p. 392).
In the mind of a child and in the experience of a psychotic person, in the thrall of powerful primitive affects, if two things feel the same, they are the same. Segal (1957) describes a woman in analysis who, before she became psychotic, wrote a story depicting her mother and Segal as being like a Lancashire witch, but when the patient became psychotic, she believed Segal was a Lancashire witch, a concrete metaphor that constituted a delusion (p. 396).
In psychosis, instead of figurative metaphorical thoughts of the “X is like Y” variety that form a basis for consensual symbols for communicating with family and community, individuals equate objects and people that share some quality of emotional significance and merge them into a single identity. Instead of “X is like Y” in psychosis “X=Y.” In Arieti’s conception of paleologic or predicate logic, elements that share the same predicate descriptors in a sentence are felt to be the same (1974). For example, a psychotic person might present to a psychiatric emergency room with the delusion he is the president of the United States, based on the following reasoning. “I live in a white house. The president lives in a white house. Therefore, I am the president.” Instead of remaining emotionally connected to the figurative metaphor “The good life I aspire to is like the life of the president,” he concludes in concrete metaphor and symbolic equivalence that he is the president. In this way concrete metaphors generate delusional beliefs. This idea that delusions can be misdirected metaphors helps link the manifestations of adult psychosis with the concrete metaphorical processes that occur in the mental life of children. Instead of expressing their feelings in figurative metaphors of the “This is like that” sort, in psychosis the person’s conflicts are experienced not as a verbal links to painful emotions and memories, but as a concrete metaphor perceived to be located in the objective world rather than felt, a “symbolic equation” in which “this” is perceived to be identical to “that.”
Eugene Bleuler (1950) noted the operation of what clinicians subsequently came to call concrete metaphor or symbolic equation a century ago in his seminal volume Dementia Praecox. Bleuler describes an exchange with a catatonic patient as follows.
In the hearing of a catatonic, something was said about a fish-market. She begins to repeat, “Yes, I am also a shark-fish.” Thus she employs an entirely peculiar and impossible clang association; impossible, that is, for every other waking human being except a schizophrenic. The association “fish-market—shark-fish” is used in order to express the idea that she is someone very bad; yet she ignores the complete impossibility of the reality of her identification (1950, p. 25).
Instead of thinking in figurative metaphor, “I am like a shark in that I have a predatory ‘I-might –bite-someone’ orally aggressive side,” she instead forms a concrete metaphor in which she makes the delusional claim of being a “shark-fish.” The figurative metaphor “I am like Y” has become “I am Y.” Many of the delusional identities that psychotic people attribute to themselves and other people can be understood as constructions of this kind in which some thought or feeling in the psychotic person is linked in association to some attribute of the self or another person, experienced not as a figurative metaphor but a symbolic equation. Instead of thinking, “I have devilish thoughts sometimes” the psychotic person might say “I am the Devil.” Instead of saying to himself in a painful state of guilt, “I betrayed her,” the psychotic person might endorse the delusion, “I am Benedict Arnold.”
Harold Searles (1962) offers a clinical example of a patient who when psychotic claimed that “people are sheep” was a literal fact, drawing no associative meaning from the figurative metaphor that modern technology has turned people into herds of sheep. As treatment progressed he began to be able to think about people in figurative metaphors.
I have been impressed repeatedly, over this past year in which his ability to communicate metaphorically has grown steadily, to see how the de-repression of long-unconscious feelings has been necessary to this process. For example, now when we are having an hour out on the lawn, as we often do, and he picks up a handful of dead leaves, shows them to me and says, “These are people,” he is very clearly saying to me, “This is how completely cast-off, useless, and forgotten some people, including me, feel themselves to be,” and is readily able, now, to elaborate upon the subject in this poignant figurative vein (1962, p. 32).
Franz Kafka’s famous story (2009) “The Metamorphosis,” in which Gregor Samsa wakes up one morning to find that he has been transformed into a monstrous insect, can be viewed as a meditation on concrete metaphor. Samsa’s feeling early in the story of being a nobody, a mere cog in the impersonal meaningless machine of business, a feeling of being like an insect, despicable and insignificant, is experienced in the story as the concrete metaphor that he is an insect. In the “psychic equivalence” mode, if two people or things share a common attribute, they are experienced not as being similar, but as being the same.
As normal development proceeds beyond the sensory-motor stage, consciousness moves beyond somatic sensations and perceptions to increasingly complex “mentalized” forms of experience, allowing for symbolic representations, figurative metaphor, verbal thought, and the telling of stories and narratives that express conscious and unconscious phantasy (Fonagy & Target, 2007). We find metaphors for things that stir our interest and our emotions. Figurative metaphors establish links between the current subjects of interest and past experiences. As Seiden (2004) notes, “The value of metaphor is that it organizes experience without needing or expecting to pin it down in any final sense” (p. 638).
Breakdown of the “Ego Boundary”
Having described how a failure to distinguish between two elements in a metaphor can lead to delusional thinking, we now turn to a second kind of difficulty in keeping things apart, a failure to distinguish between thoughts, feelings, and perceptions. Federn (1952) described this difficulty in differentiating inside from outside as a breakdown of the “ego boundary” between thoughts, feelings, and the perceived world. In his view, the brain invests certain mental experiences with the quality of “ego feeling,” which locates these experiences subjectively within the mind of the individual, while other mental events having a different subjective quality are experienced as perceptions of the objective world. What he called “ego feeling,” we would now call the “qualia” of subjective experience that mark a mental event as belonging to the self. Instead of thinking a thought or feeling an emotion as mental events distinct from a sensory impression, a psychotic woman might perceive her thoughts as meaningful distortions of the stimulus properties of the objective world (Marcus, 2003).
For example, the “voice” hearing experience is a hybrid blend of thoughts and auditory perception. As noted by Bleuler (1950) a century ago,
The patients hear their own thoughts expressed in gentle whisperings or in unbearably loud tones. “The telephone lines take up all my thoughts.” Illusions may also sometimes embody the momentary thought. “Whatever I think, the bells ring it out, the wheels creak it, the dogs bark, the birds sing it; such a thing has never happened before in this whole world” (1950, p. 98).
Searles (1962) reports that a woman who was teasing a priest with anti-Catholic jibes observed that the priest’s ears looked like a monkey’s ears; i.e., she had made a monkey out of him. Her visual experience of the stimulus properties of the priest’s ears had been altered in keeping with her emotions.
While a person without psychosis may experience a ruminative thought “I am a loser,” a person experiencing psychosis may experience such a thought as the perception of an external “voice” saying over and over again “You are a loser.” The net effect of this shift away from thought toward perception leaves the person with psychosis with the impression that events are going on in the outside world rather than in his or her mind. This shift from thought to perception places a cast of characters derived from the psychotic person’s primitive internal objects in a play produced on the stage of the real world.
People with psychosis communicate in words, verbal metaphors, and images composed of altered perceptions of the outside world that coalesce into hybrid forms of anomalous subjective experience. These are meaningful metaphorical expressions of significant aspects of the person’s mental life. Psychotic symptoms are like a rebus that joins words and images to form psychotic symptoms. These symptoms are an emotion-packed puzzle to be solved by the patient and therapist, a metaphor to be deciphered. The person hides painful aspects of his or her mental life in plain sight within the metaphorical meaning of the psychotic symptoms.
Psychotherapy invites the patient to express the metaphorical meaning of the symptom in words, which brings split-off elements of mental life back into conscious awareness, where these can be experienced within the boundary of the self, and so foster emotional growth and recovery.
The altered mental landscape composed of hybrid forms of thought, feeling, fantasy, and perception, which emerges around weakened mental boundaries provides a whole new world of opportunities for psychodynamic defense. In particular, the familiar psychological defenses of splitting and projection have a field day exploiting the weakened boundaries in the psychotic mind. Just as the watercolor artist can achieve special effects by flowing colors together on paper, individuals with psychosis can achieve psychodynamic effects by merging thoughts, feelings, and fantasies together with perceptions, mental effects in ways that cannot be achieved by with those without psychosis. New possibilities for the psychodynamic regulation of mental life sprout like new species of weeds and flowers in the psychic garden.
Consider an example of how a breakdown in ego boundaries facilitates defensive processes not available to the person without psychosis. Angelina believed that she was the Bride of Jesus. She had Type II diabetes, but she found it very difficult to control her appetite. She believed that demons, who were eating the substance of her brain, lived inside her head behind her eyes. She was required to feed these demons by eating extra-large portions. She recalled her last Thanksgiving in the supervised residence where she lived. When she realized that she would not be able to attend the Thanksgiving dinner in the residence on time for the meal, she asked another person in the residence to save a plate for her. This did not happen. When she arrived and there was nothing for her to eat, she was angry and wanted to curse the person who had failed her, but she said to herself “I am a Christian woman and the Bride of Jesus. I should forgive her. I cannot curse her.” Just then she heard what she believed to be the voice of God. God said with angry affect, “That sorry-assed bitch! You can curse her!” God then provided a list of acceptable epithets that Angelina was happy to employ. In this sequence Angelina’s anger first arises as a feeling experienced within the boundary of her own mind, where her anger elicits self-condemnation. Her anger then goes missing from her own mind and reappears projected into the mind of God, who gives permission to trash the person who disappointed her.
It is likely that biological substrates play a significant role in maintaining the boundaries between thoughts, feelings, and perceptions. Hallucinogenic drugs break down this boundary. Every practicing psychiatrist has observed that dopamine-blocking neuroleptic medication can (on occasion) mend this boundary by eliminating distressing “voices” in a matter of days or weeks. If the biological substrates that partition subjective experiences are compromised in psychosis, this disturbance in the brain may have genetic components or, as in traumagenic neurodevelopmental model (Longden & Read, 2015), these substrates might be damaged by stress-induced brain changes in reaction to chronic stress or in reaction to a single or small number of traumatic events such as a rape or the death of someone close to the person.
Biology likely plays another significant role in blurring the boundaries between thought and perception. In psychosis, the world is often suffused with a hypersalient patina reflected in the common and classic psychotic symptom of ideas of reference; the person thinks that events, which ordinarily would be of little interest take on highly significant personal relevance. The fact that this hypersalient state can sometimes be relieved by dopamine-blocking neuroleptics suggests that it has a biological foundation (Kapur, 2003). Hypersalient objects (people and things) beckon, inviting special attention, offering a ready-made container to receive projected fragments of the psychotic person’s mind. In effect, biology pulls mental experience toward hypersalient objects in the outside world in a hyper dopaminergic state, and psychology pushes mental content into the psychological objects that correspond to these elements in the objective world. The net result of this pull and push is that the psychotic person’s primitive internal object phantasies are staged in the arena of the real world.
Trauma and the Onset of Psychosis
We now have in place the first two elements of our theatrical model. Primitive internal object relations provide the cast of characters and the plot line for the psychosis. Concrete metaphor and a breakdown of the distinction between thoughts, feelings, and perceptions stage the play in the outside world. What lifts the tragic curtain on opening night?
We experience all events in daily life against a backdrop of prior expectations and unconscious phantasies. We notice and give meaning to things that matter to us, and anything that matters resonates with the unconscious object-related phantasy. Occasionally something distressing happens and we note that we are overreacting to the situation, by which we mean that our more objective assessment would give less cause for concern than we are feeling. In order to say that we are overreacting we must be implicitly aware that the event has stirred up some unconscious phantasy that leads us to view the situation as more troubling than it need be, though we may not be aware precisely what that phantasy is. Our emotional reaction may be out of proportion to the actual event as perceived by our more sober self, but our emotional reaction is quite in proportion to the unconscious phantasy that has been triggered by the event. Our overreaction reflects our transient belief that an event we unconsciously feared might happen has actually come to pass in the real world. Trauma triggers psychosis in a similar way, with important differences.
The normal and inevitable primitive unconscious object-related phantasies of childhood ordinarily fade by ages 8 to 10 years, having been replaced in good-enough family environments by more nurturing mental representations of other people. When children grow up in an environment where subtle, but nevertheless, terrible things are done to the child, as when a parent prevents the child’s authentic identity from emerging by imposing an alien image on the child of who the parent needs the child to be, or when something terrible and overt happens to the child, as when a child is physically or sexually abused or abandoned, the normal primitive unconscious phantasies do not fade, but remain latent, close to the surface of consciousness. The anxiety, terror, and hurt stirred by the child’s real experiences are similar to the emotions buried in the child’s internal object world. When a traumatic life event rips off a developmental patch that has kept the primitive object world at bay, the psychological defenses give way under the pressure of intense affects, and tides of emotion wash through the mind and ego. As Eissler (1954) noted with a patient with psychosis:
. . . an emotion once activated carried all its potentialities to full concretization; that is to say, it engulfed the whole area of the ego and led to the cathexis of all ego functions. It charged the body image, the motor system, the perceptive systems, and the representations of external reality. Moreover, the patient regularly showed, fully and obviously, a characteristic of the emotions which can be observed in the normal, sometimes faintly and occasionally quite strongly; namely, the tendency of an emotion to accumulate new energy by the activation of all memories which are closely related to it, all memories whose contents support the emotion. Thus the emotion engendered out of itself new energy (1954, p. 141).
The traumatic event sets up a forced vibration through the psyche that amplifies its intensity as it resonates with painful memories and associations. When the current life of a person with psychosis feels as if it were identical to the primitive internal object world in his mind, the real world fuses with the world of internal objects, and the curtain goes up on the tragic theater in the mind that too often becomes a chronic psychosis.
Consider an example of how the residuals of primitive internal object relations reappear in adult psychosis. Karon (1981) describes a psychotic man who believed he was being poisoned, and went on hunger strikes, “The Athenian girls are laughing at me. They say their breasts are poisoned” (p. 83). There was at first pass no apparent trauma in the patient’s history. His mother, who had breast fed him for a year and weaned him gradually, asked her son during the consultation, “Did I give you enough milk?” He replied cryptically, “The cow gave her calf milk and then kicked it. She shouldn’t do that. It’s something that happened hundreds of times in the history of the world.” Karon inferred that the cow represented his mother, the calf represented the patient, and the history of the world represented his life history. The patient complained that every time his mother fed him she got angry, or “kicked” him. This pattern was apparent in their relationship as adults. If the mother cooked a meal and he ate it, they quarreled afterwards. If she cooked and he was on a hunger strike, or if someone else cooked, there was no quarrel. When the patient was a child, his need to be fed had evidently produced anxiety in the mother, which made her angry. The same sequence occurred in their adult relationship, in which she would find pretexts for a squabble after feeding her son. In this case, the universal primitive persecutory “bad breast” of infancy was kept active in the patient’s unconscious by the mother’s resentment of her son’s dependent needs. This primitive internal object-related phantasy reemerged in his adult psychosis in the form of the Athenian girls with poisoned breasts.
The Insidious Role of Logic in the Maintenance of Delusional Beliefs
It is tempting to think that people who have psychosis become delusional because they cannot think logically. It is true that in order to endorse delusional beliefs, these individuals must ignore beliefs about the world they may have held for many years. We might regard this dismissal as illogical, but endorsing particular delusional beliefs that run counter to consensual reality does not imply a global failure of logical reasoning. In fact, individuals who experience delusions retain the capacity for logical syllogistic thinking in areas outside their emotionally charged core psychotic conflicts (Kemp, 1997). The preservation of the capacity for logic in delusional was noted decades ago by Karl Jaspers (1963) in his description of the phenomenology of psychosis in his seminal General Psychopathology.
Actually we find every degree of mental defect without delusions of any kind and the most fantastic and incredible delusions in the case of people of superior intelligence. The critical faculty is not obliterated but put into the service of the delusion (1963, p. 97).
The preservation of logical reasoning in psychosis provides another link between it and ordinary mental life, and this plays an insidious role in the formation and maintenance of delusions.
Not only can people with delusions think logically, but also the mental lives of individuals who do not have psychosis are also riddled with illogical thinking (Southerland, 2007). Consider that despite the overwhelming scientific evidence in favor of evolution, and the fact that 99% of the human genome is identical to chimpanzees, a significant percentage of the American population rejects the idea that humans evolved from apes. Such believers reject science when it conflicts with their core beliefs about the origins of humankind, but they happily fill prescriptions for antibiotics developed with the same gene sequencing techniques that unraveled the human and chimp genomes. Logic would dictate that dismissing the connections between the human and chimp genomes should cast doubt on the credibility of doctors who prescribe medications developed with the same gene sequencing technology. But this does not happen, nor should we expect it to, because human beings, whether psychotic or not, have trouble thinking logically in areas of core emotional concern, while they can think logically outside this sector of their minds. There are important differences between psychosis and ordinary mental life, but an absence of the capacity for logical reasoning is not one of them.
It is a painful irony that the preservation of the capacity for logical syllogistic reasoning, which one might naively regard as a saving grace and a pathway to sanity, is, in psychosis, also a curse. Individuals with psychosis use logic to explain the anomalous subjective experiences that are hybrid blends of thought, feeling, and perception that occur in the course of mental illness (Maher, 1988). Consider the case of David who claimed that the Central Intelligence Agency (CIA) was monitoring his thoughts with sophisticated spyware and playing his thoughts back to him through speakers planted along the sidewalk in his neighborhood. He looked for the speakers, but when he found none, he concluded that the CIA was using nanotechnology to make speakers so tiny they were impossible to see with the naked eye. David’s belief certainly would be regarded as a delusion, but it had a certain contextual logic to it when the anomalous subjective experience he was trying to explain became clear to the therapist. He was experiencing the classic psychotic symptom gedankenlautwerden, or “thoughts out loud,” a symptomatic reflection of the hyper-reflexive self-awareness common in psychosis (Sass and Parnas, 2003). Instead of just thinking his thoughts, David was “hearing” his thoughts, a phenomenon David called “the echo.” If we start from the premise that David’s internal experience was pressingly apparent and subjectively real to him, and we grant this premise as a place from which to reason, the tiny speaker delusion makes logical sense.
Consider the case of Malcolm, who reported that he was being tormented by an entity he called Psycho Girl, who, he believed, could read his mind. He thought that Psycho Girl accessed his thoughts and could observe his behavior when he was alone, and that she could broadcast this information to his fellow students at school. This was different from David’s delusional explanation of gedankenlautwerden. Malcolm reported hearing a “voice” that sounded like a woman coming from a special location that appeared to be outside his head. The seeming external spatial location of the “voice,” along with its female vocal quality, underscored for him that the “voice” was an entity outside himself. He named this “voice” “Psycho Girl.” He explained his experience of hearing his thoughts out loud as Psycho Girl reading his mind, and then immediately repeating what he had been thinking out loud. He noted the absolute fidelity of Psycho Girl’s transcription of his thoughts, which led him to believe she was enormously capable and frighteningly powerful. If we start from the premise that Malcolm’s internal experience was pressingly apparent and subjectively real to him, if we grant this premise as a place from which to reason, the Psycho Girl story makes logical sense.
Another frequent anomalous experience in psychosis is a profound change in the person’s experience of the self. Ordinarily people experience themselves as a first person “I,” with a personal point of view participating in the ongoing experience of the real world. One’s sense of self and one’s experience of the world are seamlessly intertwined. In psychosis this natural unself-conscious relationship of people to their thoughts and the perceived world is disturbed. The vital first-person “I” fades and is replaced by an uncomfortable “thinness” of being. A distant approximation of this state in ordinary life might be a profound sense of depersonalization and derealization in which one no longer experiences oneself as a thinking, feeling actor in life, but rather a confused, overwhelmed, passive observer. In this state of mind a person with psychosis might say, “I do not feel like I am thinking my own thoughts anymore. My thoughts are being inserted into my brain.”
When individuals living in this detached, hollowed-out self-state bring logic and past experience to bear on their current anomalous state of mind, they may make statements that others regard as delusional, despite there being a certain contextual logic to their remarks. When attempting to make sense of his desiccated state of mind a man with psychosis might say, “I am dead,” or “I am a ghost,” or “You and I are just a dream.” As the vital self fades, a pathological, hyper-reflexive self-awareness sets in. Instead of living a life where much in daily experience is familiar and can be comfortably taken for granted, now little is automatic or goes unquestioned. Life experience is accompanied by an insidious simultaneous introspection. For example, instead of simply enjoying the blue sky on a sunny day, the individual with psychosis might reflexively ask, “Why is blue called ‘blue’?” When the natural automaticity of the familiar erodes, the psychological basis for opinion, motivation, and action is lost, a condition the diagnostician might classify as “negative symptoms.” In this state of hypertrophied self-awareness, instead of thinking thoughts and feeling emotions, mental activity takes on the quality of perceived objects. Thoughts may have an uncanny acoustic quality, or as this condition progresses, a fully auditory quality that may be experienced as an external “voice” located outside the boundary of the self.
Clinicians who wish to do psychotherapy with persons who have psychosis must be sufficiently versed in its phenomenology so that they may understand when delusions are reasoned elaborations of anomalous experiences commonly encountered in the disorder. This familiarity deepens with experience and reading. When the therapist does not understand the subjective state the patient is trying to explain in the delusion, this confusion may lead the therapist to objectify, in the name of a symptom, what the therapist cannot empathically understand. Seemingly nonsensical statements by the patient are more easily relegated to the slag heap of a “broken brain” or a “chemical imbalance” than reasoned efforts on the part of patients to communicate with the therapist about what is going on in their minds.
Consider the story of Justine, a case that allows us to bring together all elements of the model outlined. Justine was a shy child who feared other children would reject her and leave her out of games. She described her mother as a “very quiet person who you might not know was there.” Her mother was unresponsive to Justine’s fears, and was unable to comfort her. Although Justine entered adolescence without any gross disturbances of developmental milestones, as a teenager she developed a strong interest in perfumes, and she maintained an extensive collection of body lotions and make-up. She was meticulous in her personal hygiene. At age 19 she became pregnant out of wedlock, which prompted her father to banish her from the family. Ashamed and alone, she gave birth to her child in a public shelter. In the aftermath of this trauma she began to notice people looking at her on the street while wiping their noses, coughing, or clearing their throats. After months of such ideas of reference, she thought she heard someone behind her say “That woman smells!” This ushered in a chronic paranoid psychosis centered on a delusion that she had a terrible smell. This persisted for 20 years despite “treatment as usual.”
We may surmise that to Justine her badness was reflected by mother’s detachment, and this lead to her expectation of rejection from others. As a child, Justine’s sense of badness mingled with primitive unconscious object-related phantasies of devalued anal products, a phantasy that lay dormant outside conscious awareness until it began to push into consciousness in early adolescence in the form of a reaction formation—her interest in perfumes. Unconsciously, Justine worried that she had a bad smell. Consciously, she defended against this anxiety with an excessive interest in her personal hygiene and body lotions. Were it not for the trauma of the pregnancy and her father’s rejection, Justine may have remained a shy, well-groomed woman with an extensive perfume collection. When Justine was rejected by her father, she felt powerful affects of shame, guilt, anger, and loneliness. This state of mind was a response to an adverse life event that resonated with her pre-existing unconscious phantasy that she was an anally tainted bad person.
In the face of powerful affects of shame, rage, and despair, Justine’s experience of her current reality merged with a primitive unconscious objected-related phantasy in which she was being attacked by a persecutory object because she contains stinking, bad, anal elements. Instead of expressing her feelings in the form of a figurative metaphor such as “I stink as a person,” she experienced the devastation of her self-esteem in the form of a concrete metaphor: “Other people perceive me as having a bad smell.” Her self-hatred went missing from her conscious self-image only to reemerge, hidden in plain sight, as a perceived concrete metaphor seemingly apparent in the faces of strangers on the street who Justine believed found her offensive. Instead of directly addressing the painful memories and affects associated with her traumatic pregnancy, her attention is diverted to what she considered a concrete reality that she perceived in her social surround. When she perceives her problem to be located outside herself, her direct experience of her self-hatred dims in her own mind, and is replaced by her feeling she is a pariah because of her imagined bad smell. At the age of 19 she became the social outcast she, at age five, feared she was. This story has a happy ending. She began her psychotherapy at age 42, after two decades of chronic psychosis, and after nine months of once-a-week outpatient sessions she was no longer delusional, and she understood that the “voices” she heard were her own thoughts. Reunited with her family after many years of social isolation, and full of hope for the future, she began looking for work.
In Conclusion
In response to adverse life events, psychotic adults fashion a theater of the mind out of primitive unconscious phantasies that form the basic plot line for delusions. Concrete thinking and the erosion of the biological substrates that maintain boundaries between thoughts, feelings and perceptions stage the play in the real world. Logical reasoning applied to anomalous subjective experiences ensures that the play will have a long, tragic run. This situation cries out for psychotherapy.
Postscript
The clinical papers in this volume offer illustrations of concepts outlined in the model above. Lotterman’s description of “perceptualization” notes the regressive drift in psychosis away from verbal thought toward thinking in images, the mode of thought that prevails in the first two years of life. His paper includes several examples of concrete metaphors, i.e. the patient who experienced a loss as a physical pain in her heart, Patient B who saw a “scouring pad”, which appeared “rough” and “abrasive”. The woman who was catatonic for five months illustrates how unbearable psychic pain can prompt a person to retreat from the emotional angst of the real world into an enduring psychotic state, all the while observing what is going on. In keeping with the conception of psychosis as a play staged in the real world, through “emotional induction” the patient invites the therapist to act in a play. In Knafo’s paper, the patient’s experience of “block behind his eyes” or conviction he was going blind is an example of concrete metaphor where emotions are expressed in sensory experiences and perceived images rather than words. The concrete metaphor “blinds” the patient to a broader network of associations that would give particular painful meaning to his memories and current life. The patient’s mental representation of his mother is a classic example of Klein’s “persecutory object”. When he thinks she has sent him a secret message that he is like Man Ray to emphasize his Jewish parts, he is experiencing the analyst as a “persecutory object” in the transference. In her technique she contains his emotional states within the relationship, and helps him name his emotions, and tells the patient “I will not allow you to destroy me” (like Lotterman). In Margulies, the woman who painted her ears and teeth with white-out uses a concrete metaphor to express her feelings about herself and her son. The thick scar on the male patient’s neck is likewise a concrete embodiment of a host of conflicted feelings the patient has about his father. In the same way that a skillfully crafted metaphor contains within it multiple associative lines that expand outward from a central image, in these two patients their bodies are the media in which a multifaceted metaphor is constructed. In Kimhy’s paper the patient’s delusion that he has a bad smell is a concrete metaphor that expresses his negative self image. The therapist chips away at the concrete metaphor of the bad smell, by using the CBT technique of behavioral experiments and offsetting the belief with real-world experience to the contrary. In Tai’s paper, the MOL therapist remains alert to disruptions in the flow of the patient’s thoughts that break up associational links between ideas that must be thought about for effective conflict resolution and problem solving.
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Published in print: 2016, pp. 1–148
Published online: 30 April 2018
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