Psychoanalytic witnessing as a prerequisite to psychotherapy with a severely sexually abused young adolescent male ex-inner city gang member

This paper discusses psychoanalytic witnessing as the prerequisite for psychoanalytic psychotherapy with a severely sexually traumatised young adolescent boy, Dean. This form of witnessing acted as a prior stage for treatment through the psychotherapist acknowledging Dean’s trauma, without seeking to symbolise its registration in the psychotherapeutic relationship. As sexual abuse is about something done to the person, this acknowledging crucially conveys belief in the truth of what has happened to the patient at the hands of the external world. My work with Dean taught me that such acknowledgment allows for such traumatised patients to then feel more able to accept interpretations based upon what they are doing to the external world, encapsulated in the transference to their psychotherapist. Because trauma is often so deeply felt, and leaves patients dissociated or fragmented, seeking evidence of its presence needs keen observation. Here the paper discusses an experience of bodily countertransference that alerted me to the location of Dean’s trauma’s registration in our relationship. Overall, the paper seeks to demonstrate the importance of psychoanalytic witnessing as a form of containment in itself, and the essential basis for psychotherapeutic work using symbolisation and the transference.     

Working with Psychosis

This is the first of four papers about working with psychosis in a newly established post of psycho-analytic psychotherapist in an acute psychiatric unit in Australia. In this paper the author gives an account of some early impressions and experiences with staff and patients, particularly connected with an unacknowledged grief in the aftermath of psychosis. The author next discusses some of the psycho-analytic theory about psychosis which he found containing and helped make some sense of his experiences. He then introduces a case study of an exploratory psycho-analytic psychotherapy with a 40-year-old man suffering from a bi-polar disorder. The beginning of the therapy is described when this man revealed feelings of grief and despair about his illness. Being able to face and bear these feelings enabled him to begin to mourn what was irretrievably lost because of his illness and to contemplate what might still be possible. The author describes some of the early themes and one session in detail, and discusses how fluctuations in contact with the client reflect his retreat to a pathological organization in the mind. This psychic retreat was dominated by a psychotic process, and the retreat offered refuge from a dread of fragmentation and the pain of mourning and loss.     

Gef?hrliche N?he

The author examines the association between trauma and psychosis. To illustrate this he presents clinical examples of active and passive experiences of violence by adult psychotic patients, for whom forerunners in the form of childhood experiences of violence were found in some psychoanalytical treatments. They take place in traumatic relationships. Recent empirical studies have shown that trauma plays an influential role in the pathogenesis of schizophrenia. Traumatic relationships have a contradictory structure which possesses an impressive similarity to the schizophrenic dilemma of adult psychotics. The author therefore considers the schizophrenic dilemma as an introspective manifestation of a traumatic relationship, a part of the violent nature of psychiatric institutions as re-enactment of the traumatic relationship.     

ENCOUNTERS WITH PSYCHOSIS

This essay offers a personal account of one physician's attempt to engage with psychotic patients in an inner‐city hospital. It considers some of the obstacles to psychoanalytic work with psychotic patients, including anxiety in the psychotherapist, anxiety in the patient, institutional resistances, and paradigmatic errors. A discussion of paradigmatic errors in Western mental health care is expanded upon. Rorty's ( 1979 ) critique of objectivity and Kuhn's ( 1962 ) work on scientific paradigm shifts are discussed in an attempt to demonstrate how we might better understand psychosis as an illness and connect with patients across the entire diagnostic spectrum.     

The relationship between bullying, psychotic-like experiences and appraisals in 14-16-year olds

The psychological consequences of bullying have been the focus of much research over the last 25 years. However, the relationship between bullying and psychotic experiences has been relatively ignored despite the weight of evidence which suggests that traumatic events in childhood are significantly related to psychotic disorders. 373 pupils aged between 14 and 16 years took part in the study. They were asked to complete a number of self-report measures which examined their experience of bullying, predisposition to auditory hallucinations, paranoia and dissociation, and beliefs about both the self and the world and about paranoia. It was found that bullying was significantly associated with predisposition to psychotic experiences. Negative post-trauma cognitions were also associated with predisposition to psychotic phenomena as were positive beliefs about paranoia. Being bullied at school and beliefs about trauma and psychotic symptoms may contribute to the development of psychosis. However, it is also possible that these results indicate that experiencing psychotic-like phenomena increases the likelihood that a pupil's interpersonal context is characterised by peer hostility and rejection. The implications of these results are discussed.     

Childhood trauma and psychosis: Review of the evidence and directions for psychological interventions

There is controversy over whether childhood trauma (CT) is a causal risk factor for psychosis. The aim of this study was to provide psychologists with a brief overview of the research into relationship between childhood trauma and psychosis and directions for psychological interventions. It details six of the highest quality studies in the area and tentatively concludes from these that there is evidence for a relationship between CT and psychosis. Hallucinations and delusions have been implicated as important factors in the relationship between CT and psychotic disorder and these are discussed, along with post‐traumatic intrusions and schemas, which have been conceptualised as part of the psychological mechanisms whereby CT confers a risk for psychosis. The development of psychological interventions for people with psychosis who have experienced CT is in its infancy but has been based on evidence‐based cognitive behavioural interventions in psychosis and post‐traumatic stress disorder. A formulation‐based approach is described in this paper, along with a case study.     

Accuracy and bias in the perception of the partner in a close relationship

Partners in close relationships can be both accurate and biased in their perceptions of each other. Moreover, sometimes a bias can lead to accuracy. The authors describe a paradigm for the simultaneous measurement of accuracy and bias in 2-person relationships. One prevalent bias in close relationships is assumed similarity: Does the person think that his or her partner sees the world as he or she does? In a study of 238 dating and married heterosexual couples, the authors found evidence for both bias and accuracy: the bias effects were considerably stronger, especially when the measure was linked to the relationship. They found little or no evidence for gender differences in accuracy and bias.     

HAROLD SEARLES: LIFELONG WORK OF A MASTER CLINICIAN

Harold F. Searles was one of the most gifted and innovative clinicians of psychoanalysis. His clinical work arouses interest on its own merit, as well as for the ways in which it shaped his highly innovative thinking. We can only imagine what special processes were developing in Searles’s inner world under the everlasting impact of his experience with psychotic patients and from his life in general. Searles focused extensively on how the psychotic individuals’ mental distortions impacted their capacity to form personal relationships in general, and the role of the analyst and countertransference in treatment. This unique viewpoint helped him sustain a creative commitment to psychotic patients, regarded by many as unsuitable for psychoanalysis.     

The theory of gender identity disorders

Experience with more than 500 patients over the last decade has led to the conclusion that the quest for sex reassignment is a symptomatic compromise formation serving defensive and expressive functions. The symptoms are the outgrowth of developmental trauma affecting body ego and archaic sense of self and caused by peculiar symbiotic and separation-individuation phase relationships. The child exists in the pathogenic (and reparative) maternal fantasy in order to repair her body image and to demonstrate the interconvertability of the sexes. Gender identity exists not as a primary phenomenon, but in a sense as a tertiary one. There is, no doubt, a tendency to gender-differentiate in a way concordant with biological endowment. Nevertheless, gender formation is seriously compromised by earlier psychological difficulty. Gender identity is a fundamental acquisition in the developing personality, but it is part of a hierarchical series beginning with archaic body ego, early body image, and primitive selfness, representing their extension into sexual and reproductive spheres. Gender identity consolidates during separation-individuation and gender pathology bears common features with other preoedipal syndromes. Transsexualism is closely linked to perversions, and the clinical syndromes may shade from one into another. However, what is kept at the symbolic level in the perversions must be made concrete in transsexualism. In this regard there is a close relation to psychosis. The clinical complaint of the transsexual is a condensation of remarkable proportions. When the transsexual says that he is a girl trapped in a man's body, he sincerely means what he says. As with other symptoms, however, it takes a long time before he begins to say what he means.     

Coherent Themes: Individuals’ Relationships with God,Their Early Childhood Experiences,Their Bonds with Significant Others,and Their Relational Delusions During Psychotic Episodes All Have Similar Holistic,Existential, and Relational Themes

An adult seems to articulate surprisingly similar meaning themes and similar processes about relationships in several widely disparate domains of behavior, domains of both non-pathological and pathological types. Whether the person is consciously describing early relationships with parental figures, unconsciously acting them out in current relationships, experiencing relationships with God or the Transcendent, or acting on the basis of relational delusions during psychotic episodes, his or his experienced relational reality seems to be filtered through a single, coherent, personally unique spiritual, existential, and epistemological relational lens. Conflicts may involve other relational meanings, but may be conflicts because of the existence of that dominant lens. Two parts of that dominant lens system, specifically the part relating the person’s concept of God to the other parts of the system and the part relating the specifics of psychotic breaks and spiritual emergence to other parts of the system, are seldom discussed. Both understanding the person’s dominant relational lens and the implications of that person’s using the lens to see reality, and sharing that knowledge with the individual (if he or he has stabilized to some degree) can help the troubled or disoriented individual. That person can gradually give a more adaptive meaning to consistent distortions in the many areas of meaning and behavior attached to relationships, and even to very skewed behavior such as hallucinations and delusions during psychotic breaks. Distortions during experiences of spiritual emergence also can be made clearer to the disturbed client if the therapist has a better understanding of the person’s overall coherent relational meaning system and its implications, and can translate the language of that system into spiritually transformative terms. A case is summarized and discussed as an example of these ideas. Then, two theories are described. A useful theory of human-felt connection and a cognitive developmental theory of Postformal Complex Thought have been developed by the author and described in earlier publications. These two theories help make sense of the multiple but coherent themes, cognitive dimensions of theme genesis and change, and the nature of the relational lenses used. Suggestions about interventions in the person’s system of coherently distorted relational themes, suggestions based on the two theories, are discussed. The recommendation is made that all therapists become fluent in the languages of, and especially the connections among, all of the relational areas named in the title of this paper that are part of the coherent relational theme.     

Kant on the Number of Worlds

It has long been disputed whether Kant's transcendental idealism requires two worlds – one of appearances and one of things in themselves – or only one. The one-world view must be wrong if it claims that individual spatio-temporal things can be identified with particular things in themselves, and if it fails to take seriously the doctrine of double affection; versions that insist on one world, without making claims about the identity of individual things, cannot say in what way the world as we know it and the world of things in themselves can be ‘the same’. The two-world view must be wrong if it denies Kant's empirical realism, or offers a phenomenalist interpretation of it. On moral grounds Kant ‘identifies’ each human person with a particular thing in itself, but the relationship here cannot be strict identity; instead its closeness may warrant regarding the two distinct entities as part of a composite whole. Perhaps up to the first edition of the Critique, Kant thought that empirical knowledge required a particular kind of close correspondence between appearances and things in themselves, one that would make it appropriate to speak of composite wholes here also. By the time of the second edition, he saw that there could be no good grounds for thinking that. In this respect something a bit like the one-world theory might make more sense for the first edition than for the second; but in both cases there is room to speak of two worlds as well. Talk of the number of worlds is metaphorical, and both metaphors have their dangers.     

Developmental Process of Japanese Psychotherapists Based on Their Life Histories

We identified the mastery processes of experienced psychotherapists by drawing their life histories, which indicated principles for guiding the development of young psychotherapists. Participants were psychotherapists with over 30 years of experience (N = 7, six men and one woman, mean age = 71.86 years). The data were analyzed using the trajectory equifinality model (TEM). The results indicated that a psychotherapist might continue to practice even while experiencing conflicts and might eventually integrate and establish their unique therapeutic approach into their work. Essential factors in facilitating the motivation to be a psychotherapist include: hope; good friends, coworkers, and supervisors; experience with many cases; learning from a global perspective; and interest in human beings. Moreover, after the mid-career, adverse events in participants' private lives had positive effects on their development as experts. It was concluded that the development of a psychotherapist is a process of growth as a person. This study indicated factors necessary to continue as a psychotherapist while facing conflicts, which is considered useful for educating future Japanese psychotherapists.     

'Poor girl': a case of active psychosis

The paper provides a structural account of a clinical case of psychosis based on a two-year analysis conducted from a Lacanian perspective. It illustrates the Lacanian theoretical and clinical approach to psychosis through discussing the different phases of the analytic work with the particular analysand from her gradual stabilization to her breakdown and hospitalization. Following through the development of the analysis in a chronological order enables a presentation of the different modalities of psychotic transference at different points in the work as well as a discussion of the mechanisms responsible for stabilization and, conversely, psychotic breakdown. The paper discusses the use of language in psychosis as well as the strategies of binding jouissance that the analysand developed as a means of preventing psychotic crises and maintaining a functional relation to the world. Finally,issues are raised about the aim and direction of psychoanalytic treatment of psychosis.     

Does Integrity Require Moral Goodness?

Most accounts of integrity agree that the person of integrity must have a relatively stable sense of who he is, what is important to him, and the ability to stand by what is most important to him in the face of pressure to do otherwise. But does integrity place any constraints on the kind of principles that the person of integrity stands for? In response to several recent accounts of integrity, I argue that it is not enough that a person stand for what he believes in, nor even that he is committed to and stands for what, in his best judgement, is morally right. In our web of moral concepts integrity is internally related to a host of virtues which exclude weakness of will and dogmatism, and presuppose trustworthiness. Integrity requires that the principles stood for must be those that a morally good, morally trustworthy agent would stand for, and that the agent himself is morally trustworthy.     

The relationship between personality traits and psychotic like experiences in a large non-clinical adolescent sample

ObjectiveThe relationship between personality and psychosis is well established. It has been suggested that this relationship may be partly accounted for by higher levels of depression in individuals with certain personality traits. We explored whether the link between personality and psychotic symptoms is already apparent in adolescence, and if this association would still hold when depression was controlled for.Method654 secondary school students were surveyed via self-report questionnaires measuring the Five-Factor model of personality (NEO-FFI), depression (CES-D) and psychotic-like experiences (CAPE).ResultsPositive associations were found between Neuroticism and all CAPE-subscales except Magical Thinking, which was in turn associated with all other personality traits when at high levels. Agreeableness was negatively associated with all CAPE-subscales, while Openness to Experience was only positively associated with Persecutory Ideas and Magical Thinking. After controlling for depression, many of the significant associations remained.ConclusionOur findings suggest that the chance of having psychotic like experiences is more likely for adolescents with certain personality traits. These associations are not fully explained by depression, especially when psychotic experiences are at higher levels. Future research is needed to investigate if these personality traits might put a person at risk for the development of full-blown psychosis.     

Politics on the Couch? Psychotherapy and Society—Some Possibilities and Some Limitations

The ideas and practices of psychotherapy, together with fresh thinking from many other sources, can help to revitalize Western politics which seem broken and moribund. The author describes various professional experiences of his own at the interface of politics and psychotherapy. These include consulting with mainstream and activist politicians and groupings. He discusses how politics in the West is changing in the general direction of what he calls “transformative politics.” He also asks if psychotherapists can make a difference in the political world today, explaining that, though enthusiastic about the prospect, he is also skeptical about it because the record of psychotherapists' involvement in politics is not very good. The paper includes an experiential and personally oriented section (“The Inner Politician”) that looks at how the political self is formed in culture, family, and the inner world. The notion of differing political styles as a source of conflict is explained and explored. The author concludes with some reflections on the relations between psychotherapy, politics, and spirituality.     

Empathy and the responsiveness to social affordances

The direct perception theory of empathy claims that we can immediately experience a person’s state of mind. I can see for instance that my neighbour is angry with me in his bodily countenance. I develop a version of the direct perception theory of empathy which takes this perceptual capacity to depend upon recognising in what way the other person is responsive to the affordances the environment provides. By recognising which possibilities for action are relevant to a person, I can thereby understand something about the meaning they give to the world. I come to share something of their perspective on the world, and this allows me to grasp based on my perception of them something about their current state of mind. I argue that shared affect plays a central role in this perceptual capacity. Shared affect allows me to orient my attention to possibilities for action that matter to the other person. I end by briefly discuss the implications of this view of empathy for the disturbances in so-called “cognitive empathy” that are found in people diagnosed with autism spectrum disorder.     

If This Is My Body … : A Defence of the Doctrine of Doing and Allowing

I defend the Doctrine of Doing and Allowing: the claim that doing harm is harder to justify than merely allowing harm. A thing does not genuinely belong to a person unless he has special authority over it. The Doctrine of Doing and Allowing protects us against harmful imposition – against the actions or needs of another intruding on what is ours. This protection is necessary for something to genuinely belong to a person. The opponent of the Doctrine must claim that nothing genuinely belongs to a person, even his own body.     

A Phenomenological Analysis of the Psychotic Experience

Six individuals with experience of psychosis were interviewed about their psychotic experiences. The material was analyzed using the empirical phenomenological psychological method. The results consist of a whole meaning structure, a gestalt, entailing the following characteristics: The feeling of estrangement in relationship to the world; the dissolution of time; the loss of intuitive social knowledge; the alienation of oneself, and finally; the loss of intentionality/loss of agency. In brief, the results show that an altered perception of the self and the world was an essential part of the psychotic experience where subjects described themselves as changed; something was sensed as being wrong as psychosis is perceptible but hard to communicate. The normal life-world experience was altered and reality seemed strange. Time perception seemed to be changed as temporality appeared dissolved and the experience of time was focused on the current moment excluding the future. The subjects described loss of intentionality, they were no longer agents in their actions but partly steered by others and they could feel as if their experiences were not theirs. The patients also describe problems regarding their ability to socialize and communicate with others. They seem to lose their intuitive social capacity and were prone to suspiciousness.     

The symbolic and concrete: Psychotic adolescents in psychoanalytic psychotherapy

Unique disturbances in symbolisation are characteristic of the pathology of schizophrenia. Drawing on the case vignette of a psychotic adolescent, the author discusses theoretical problems in the symbolisation process in general and then in psychosis, in particular the relation between 'concretism' as a thought disorder and other psychotic defences. The ability to symbolise on the one hand and to maintain sufficiently stable ego boundaries on the other hand are examined in their relation. The author's clinical experience supports her hypothesis that there is a close relationship between the impairment of the symbolisation process in the adolescent or adult psychotic patient and his/her inability to engage in symbolic play as a child. Special attention is paid to the role of early trauma and consequent pathology of object relations for disturbances of symbolic play in childhood. Regression to concrete thinking is understood as the chance of the psychotic patient to give some meaning to reality in an unreal, delusional world and as his/her last chance to communicate at all. Conclusions are drawn for psychoanalytic techniques in the treatment of patients who are deeply regressed in this respect. Special attention is given to the particular circumstances and challenges of adolescence and to providing psychoanalytic psychotherapy to adolescent psychotic patients.