Mourning and psychosis: a psychoanalytic perspective

The author attempts to develop some of the basic models and concepts relating to mourning processes in psychotic patients on the assumption that situations of loss and mourning are key moments for psychoanalysis, psychotherapy, and therapeutic approaches in general. Secondly, he reminds us that 'mourning processes in psychotics' are not always 'psychotic mourning processes', that is to say, that they do not necessarily occur within, or give rise to, a psychotic clinical picture. These ideas are illustrated by a number of sessions and vignettes concerning two psychotic patients in psychotherapeutic and psychoanalytic treatment. In theoretical terms, it seems vitally important in this context to combine a relationship-based approach within a framework of special psychoanalytic psychopathology with an updated view of processes of mourning and affective loss. A fundamental requirement at clinical level is to determine the role to be played by psychoanalytically based treatments in combined, integrated or global therapies when working with psychotic patients. For this purpose, the paper ends by outlining a set of principles and objectives for such treatments.     

THE SURVIVING SIBLING: THE EFFECTS OF SIBLING DEATH IN CHILDHOOD

This paper considers the case of childhood mourning in which there is an increased possibility of a pathological grief reaction, due to an incapacity to sustain mourning and an inability to comprehend death. The death of a sibling in childhood is a complex loss to manage, the outcome of which is inextricably linked with parental grief. Maladaptive parental mourning processes, including the phenomenon of the ‘replacement child’, are explored. The effects of this loss on the surviving sibling can give rise to a variety of symptoms that may impair emotional development. Amongst the main responses experienced by the surviving sibling is that of a guilt reaction, not only for having survived when the sibling did not, but also a fear that harboured death wishes may have caused the tragedy. Premature death anxiety and distorted concepts of illness are further possible outcomes of this event. It is suggested that the primary deprivation a child may experience when their sibling dies is the emotional absence of their parents who are preoccupied with their own grief.     

The impact of a subsequent pregnancy on grief and emotional adjustment following a perinatal loss

The present study examined the impact of a subsequent pregnancy on emotional adjustment associated with a previous perinatal loss and on the following components of parental grief—active grief, difficulty coping, despair. Participants included 25 women and 24 partners who were expecting a baby for the first time since their loss and 25 women and 18 partners who were not expecting and had not had a child or pregnancy after their loss. Depressive symptomatology, anxiety, marital adjustment, as well as active grief, despair, and difficulty coping were measured. Mothers who were not pregnant were experiencing significantly higher levels of despair and difficulty coping than pregnant mothers, independently from the effect of time elapsed since the loss. For the fathers, no significant group effect in emotional distress or intensity of grief was found. Women reported significantly higher levels of negative affectivity than men. A new pregnancy may be associated with a beneficial effect on the mourning process of women with a previous perinatal loss, primarily by decreasing their despair and difficulty coping. However, in our sample, grief intensity remained high, suggesting that the mourning process may not be hindered by a subsequent pregnancy.     

Object loss, renewed mourning, and psychic change in Jane Austen's Persuasion

Austen's extraordinary realism in depicting the dynamic internal processes which follow on the heroine's loss in Persuasion becomes clear in the light of a psychoanalytic understanding of mourning. Persuasion dramatizes the effects of a mother's death in adolescence as these come into play at the time of the heroine's separation from her fiancée and her later mourning. The thesis of this paper is that, despite falling in love with the brilliant hero, an unfinished mourning and an unconscious identification with her dead mother helped to persuade the heroine Anne Elliot to break her engagement, to create a 'final parting' as her mother had done to her in dying. The heroine's internal monologues show that she has projected some of the darker feelings of mourning, her anger and resentment, on to the hero and that she reopens a complex mourning process, partly through the displacement of affect, showing how traumatic effects of loss can be worked through in deferred action, effecting positive psychic change.     

Anatomy of Regret: A Developmental View of the Depressive Position and a Critical Turn Toward Love and Creativity in the Transforming Schizoid Personality

This article deals with critical psychic transformation in a schizoid personality disorder that evolves in an object relations psychoanalysis in which "developmental mourning" plays a central role. Within a mourning process that allows for the grieving of loss related to arrested separation-individuation development, the analysand confronts the existential grief of regret that had always unconsciously haunted her. The unconscious guilt related to the existential grief of regret had caused much dissociation of self-experience and affect states. The analysand acknowledges her own part in the destruction of primal and current relationships after the traumatic impact of her early life is understood. This allows her to repair current relationships, both within her internal and external worlds so that she can open to capacities for love and creativity. The analysand's courage to consciously grapple with her regret (loss and guilt combined) allows her to relinquish self-sabotaging character defenses such as contempt and emotional withdrawl. Consequently, a second marriage is salvaged and enriched, and the analysand's relationship with her two children is dramatically improved.     

Do Patients With Psychosis Experience Loss and Grief As a Result of Their Illness?

BACKGROUND: Depression and suicidality are frequently reported in patients with psychosis and schizophrenia, but the grief process that may be associated with this illness has not been systematically studied. In this study, we examined whether patients diagnosed with psychosis identify, grieve, and mourn losses engendered by the illness. METHOD: 24 patients diagnosed with psychosis in the past five years were surveyed to indicate whether their illness led to losses, and to describe their responses to the losses. Psychosis-related perceived losses were surveyed using three subscales of a loss and grief questionnaire (loss of self, self-care, and roles). Their relationship with beliefs about the illness, symptomatology, coping style, and self-efficacy and insight was studied. RESULTS: 23 (96%) patients named specific losses, and 16 patients (67%) reported feelings associated with grief and mourning. More than half reported loss of self-esteem at the onset of illness and only half saw themselves as having improved in the past month. Patients reported more loss within the past month than at the onset of illness. In the past month, patients with an intact sense of self experienced greater self-efficacy (r = .568, p < .004) while those with loss of self reported feelings of shame (r = ?.582, p < .003). Only patients with insight associated the onset of illness with loss. In the past month, most patients saw themselves as experiencing loss. DISCUSSION: The study results suggest that at some distance from diagnosis, patients still experience themselves as having much loss due to their illness. These unresolved feelings may indicate complicated mourning. Insight appears to be associated with the ability to look back at the onset of the illness and recognize that it engendered losses. Further study of the process of and barriers to grief and mourning is recommended. In clinical practice, the assessment of grief as a part of post-psychotic recovery could lead to providing more appropriate treatment and lead to a positive outcome.     

Reminiscence,Ritual, and Beyond Working Through: Commentary on Papers by Joyce Slochower and by Laura Impert and Margaret Rubin

The author examines, contextualizes, and elaborates upon Slochower's psychoanalytic exploration of commemorative rituals and, more specifically, the Jewish tradition of Yitzor as well as upon Impert and Rubin's understanding of embodied nostalgic reminiscences, considering them within a therapeutic context for the mourner entering into the clinical situation. Slochower's experience with commemorative rituals as facilitating environments for the restoration or support of potential space and memorial activity suggests that they can aid in the re-construction and re-shaping of emotional memory, going beyond a notion of “working through.” Impert and Rubin suggest that generative nostalgic reminisces, a soma-sensory based form of memory that holds the potential for activating arrested mourning, may be clinically usefully in awakening dormant or dissociated grief so that patients can access mourning. Extending upon these contributions, the author further considers the possibility that mourning might be more usefully conceived as processes of transformational work for which a fixed resolution or outcome is neither proscribed nor prescribed. This transformational work may be seen, in part, as ongoing cycles of self-surrender to the mourner's swirling constructions of attachments lost, re-found, re-remembered, and re-conceived.     

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.     

Affective consciousness: Core emotional feelings in animals and humans

The position advanced in this paper is that the bedrock of emotional feelings is contained within the evolved emotional action apparatus of mammalian brains. This dual-aspect monism approach to brain-mind functions, which asserts that emotional feelings may reflect the neurodynamics of brain systems that generate instinctual emotional behaviors, saves us from various conceptual conundrums. In coarse form, primary process affective consciousness seems to be fundamentally an unconditional "gift of nature" rather than an acquired skill, even though those systems facilitate skill acquisition via various felt reinforcements. Affective consciousness, being a comparatively intrinsic function of the brain, shared homologously by all mammalian species, should be the easiest variant of consciousness to study in animals. This is not to deny that some secondary processes (e.g., awareness of feelings in the generation of behavioral choices) cannot be evaluated in animals with sufficiently clever behavioral learning procedures, as with place-preference procedures and the analysis of changes in learned behaviors after one has induced re-valuation of incentives. Rather, the claim is that a direct neuroscientific study of primary process emotional/affective states is best achieved through the study of the intrinsic ("instinctual"), albeit experientially refined, emotional action tendencies of other animals. In this view, core emotional feelings may reflect the neurodynamic attractor landscapes of a variety of extended trans-diencephalic, limbic emotional action systems-including SEEKING, FEAR, RAGE, LUST, CARE, PANIC, and PLAY. Through a study of these brain systems, the neural infrastructure of human and animal affective consciousness may be revealed. Emotional feelings are instantiated in large-scale neurodynamics that can be most effectively monitored via the ethological analysis of emotional action tendencies and the accompanying brain neurochemical/electrical changes. The intrinsic coherence of such emotional responses is demonstrated by the fact that they can be provoked by electrical and chemical stimulation of specific brain zones-effects that are affectively laden. For substantive progress in this emerging research arena, animal brain researchers need to discuss affective brain functions more openly. Secondary awareness processes, because of their more conditional, contextually situated nature, are more difficult to understand in any neuroscientific detail. In other words, the information-processing brain functions, critical for cognitive consciousness, are harder to study in other animals than the more homologous emotional/motivational affective state functions of the brain.     

Growth in emotional intelligence. Psychotherapy with a learning disabled girl

This paper describes the once-weekly psychoanalytic psychotherapy of a girl, called Ellie, aged eight at the start of her treatment. Ellie had a learning disability and displayed difficult behaviour at school and at home. In her therapy, Ellie grew in emotional intelligence, more in touch with and able to express her feelings. Her behaviour improved and so did her capacity to learn. In the therapy there were certain limitations to progress and this is discussed in terms of how Ellie's disability affected the basic achievements of emotional development, including a mind with a solid ‘reality ego’, able to contain anxiety, and able to maintain depressive functioning. The importance of parallel parent work, to share observations and understanding of the child's functioning is discussed. Difficulties for both child and parents in dealing with the pain of difference and how this limits emotional intelligence are discussed. The author hopes that this paper will encourage the offering of psychoanalytic psychotherapy to children and young people with learning disabilities, who are significantly more likely to suffer from mental health problems than their peers.     

A Dialogue on Racial Melancholia

As Freud's privileged theory of unresolved grief, melancholia presents a compelling framework to conceptualize registers of loss and depression attendant to both psychic and material processes of Asian American immigration, assimilation, and racialization. Freud initially formulates melancholia as a pathological form of individual mourning for lost objects, places, or ideals. However, we propose a concept of melancholia as a depathologized structure of everyday group experience for Asian Americans. We analyze a number of Asian American cultural productions (literature and film) as well as two case histories of university students involving intergenerational conflicts and lost ideals of whiteness, Asianness, home, and language. Exploring these analyses against Klein's notions of lost objects, we propose a more refined theory of good and bad racialized objects. This theory raises the psychic and political difficulties of reinstatement and the mediation of the depressive position for Asian Americans. In addition, this theory suggests that processes of immigration, assimilation, and racialization are neither pathological nor permanent but involve the fluid negotiation between mourning and melancholia. Throughout this essay, we consider methods by which a more speculative approach to psychoanalytic theory and clinical practice might offer a deeper understanding of Asian American mental health issues.     

Mourning the dead,mourning the disappeared: The enigma of the absent–presence

Freud's interest in the impact of death on the living goes back further than Mourning and Melancholia (1917e, [1915]). In Totem and Taboo (1912–13) Freud noted the ambivalence of the emotions we experience in relation to the dead. In this paper, I focus on Mourning and Melancholia as a landmark in the understanding of both the normal and psychopathological aspects of mourning and depressive processes in human beings. Mourning and Melancholia bridges Freud's first and second topographic theories of the psychic apparatus and constitutes for many authors the foundation of his theory of internal object relations. With this psychoanalytic understanding of mourning as a framework, I discuss ‘special mourning processes,’ such as the those confronted by psychoanalysts in Argentina when treating the relatives of thousands of people who were ‘disappeared’ by the military dictatorship in the 1970s; they are ‘special’ in the sense that the external reality [which] constitutes the starting point of the psychic mourning process, as described by Freud, is absent. I argue that the ‘absent–presence’ of the body as an enigmatic message initiates a special mourning process that bears certain characteristics of, and is isomorphic to, Laplanche's seduction theory.     

Treatment of grief and mourning through EMDR: Conceptual considerations and clinical guidelines

IntroductionEye Movement Desensitization and Reprocessing (EMDR) is an empirically-supported psychotherapeutic approach for treating trauma, which is also applicable to a wide range of other experientially-based clinical complaints. It is particularly useful in treating grief and mourning.Literature findingsEMDR is guided by the Adaptive Information Processing Model (AIP), which conceptualizes the effects of traumatic experiences in terms of dysfunctional memory networks in a physiologically-based information processing system. Numerous empirical studies have demonstrated EMDR's efficacy.DiscussionThe death of a loved one can be very distressing, with memories and experiences associated with the loss becoming dysfunctionally stored and preventing access to adaptive information, including positive memories of the deceased. EMDR can be utilized to integrate these distressing experiences and facilitate the assimilation and accommodation of the loss and movement through the mourning processes.ConclusionApplying the eight phases of EMDR to grief and mourning can yield potent clinical results in the aftermath of loss.     

Beyond Broken Bonds and Broken Hearts: The Bonding of Theories of Attachment and Grief

Attachment theory describes the establishment and long-term impact of infants' early relationships. Theories of grief and mourning have acknowledged that the disruption of attachment bonds is loss and grief, but the attachment literature shows little development toward a conceptual linkage with these theories. The connection is important given the current discussion of whether bonds with the deceased are broken or continued. The purpose of this article is to link the strengths of each perspective to inform us about the process of grief as mourners work through the reconstruction of their relationships. It presents a developmental model integrating attachment theory and cognitive developmental approaches in order to further our understanding of the processes involved in loss and grief.     

Fracturing drive or fracturing connections—relational considerations commentary on paper by Paul Williams

We tend to conceive of mourning primarily in intrapsychic terms. In this commentary I highlight how Harvey Peskin’s paper (this issue) helps us to appreciate that grief is not only the product of the individual mind but is also constituted relationally. Both what we experience in our grieving and how we express it is shaped by and through those around us whose grief we bear witness to, as we ourselves grieve and are witnessed by them.

I elaborate further on Peskin’s view of the role of witnessing during grieving and mine another profound implication in his discourse by pointing to the bidirectional influence between mourning and relationality. Not only is mourning fostered through relational engagement, but our grieving together can provide the mortar for the building and sustaining of community.     

Nostalgia and lost identity

Nostalgia for the Soviet Union is a major social phenomenon in Russia today due to the irrevocable losses of the recent past in which Soviet citizens involuntarily became immigrants in their own country. With reference to discussions of nostalgia in philosophical and psychoanalytic literature, I suggest that nostalgia may represent either a defensive regression to the past or a progressive striving for wholeness through re‐connecting with what has been lost in the service of a greater integration. I compare this with the processes of adaptation seen in immigrants and provide a clinical illustration of a young man coming to terms with loss and change in the post‐Soviet era. When nostalgia is recognized as a legitimate emotional experience it may facilitate mourning and enable the integration of the past with the present and the development of a new identity.     

Phantastic objects and the financial market's sense of reality: a psychoanalytic contribution to the understanding of stock market instability

This paper sets out to explore if standard psychoanalytic thinking based on clinical experience can illuminate instability in financial markets and its widespread human consequences. Buying, holding or selling financial assets in conditions of inherent uncertainty and ambiguity, it is argued, necessarily implies an ambivalent emotional and phantasy relationship to them. Based on the evidence of historical accounts, supplemented by some interviewing, the authors suggest a psychoanalytic approach focusing on unconscious phantasy relationships, states of mind, and unconscious group functioning can explain some outstanding questions about financial bubbles which cannot be explained with mainstream economic theories. The authors also suggest some institutional features of financial markets which may ordinarily increase or decrease the likelihood that financial decisions result from splitting off those thoughts which give rise to painful emotions. Splitting would increase the future risk of financial instability and in this respect the theory with which economic agents in such markets approach their work is important. An interdisciplinary theory recognizing and making possible the integration of emotional experience may be more useful to economic agents than the present mainstream theories which contrast rational and irrational decision-making and model them as making consistent decisions on the basis of reasoning alone.     

An empirical study of seriously disturbed suicidal patients

Aspects of unconscious processes in a group of seriously disturbed psychiatric patients are examined in an effort to predict near-lethal suicide attempts and explore psychoanalytic formulations of suicide. The Rorschach Inkblot Test, the most widely used projective measure in suicide research (Bongar 1991), was chosen for its potential to shed light on specific unconscious processes. Psychic states commonly associated with suicide were measured by psychoanalytic Rorschach analog scales and then subjected to a progression of statistical analyses in order to predict future occurrence and lethality of suicide attempts. On the basis of a priori hypotheses, the authors developed a suicide index comprising four psychoanalytic Rorschach signs that predicted, with considerable accuracy, which patients would later make near-lethal suicide attempts. The best predictors were unconscious processes indicative of penetrating affective overstimulation, disturbance in the capacity to maintain adequate ego boundaries, and depressive affective states characterized by a morbid preoccupation with death and inner decay. These findings provide empirical support for several well-known formulations of the unconscious motivations for suicide.     

Neurologizing the Psychology of Affects: How Appraisal-Based Constructivism and Basic Emotion Theory Can Coexist

ABSTRACT— Abundant neurobehavioral data, not discussed by Lisa Feldman Barrett (2006) , support the existence of a variety of core emotional operating systems in ancient subneocortical regions of the brain ( Panksepp, 1998a, 2005a ). Such brain systems are the primary-process ancestral birthrights of all mammals. There may be as many genetically and neurochemically coded subcortical affect systems in emotionally rich medial regions of the brain as there are "natural" emotional action systems in the brain. When emotional primes are aroused directly, as with local electrical or chemical stimulation, the affective changes sustain conditioned place preferences and place aversions, which are the premier secondary-process indices of affective states in animals. Humans are not immune to such brain manipulations; they typically exhibit strong emotional feelings. Human emotion researchers should not ignore these systems and simply look at the complex and highly variable culturally molded manifestations of emotions in humans if they wish to determine what kinds of "natural" emotional processes exist within all mammalian brain. Basic emotion science has generated workable epistemological strategies for understanding the primal sources of human emotional feelings by detailed study of emotional circuits in our fellow animals.