Chapter 14 – Psychological Approaches to Psychosis


This chapter will describe the psychological processes thought to underlie psychosis and how these approaches can assist our understanding and management of psychotic disorders. There is no single model for complex conditions and the main theoretical underpinnings and treatment approaches derived from psychodynamic, systemic and cognitive behavioural frames of reference will be outlined. Clinical examples will illustrate the application of these ideas in clinical care.

Chapter 14 Psychological Approaches to Psychosis

Jo O’Reilly

We can’t cure a patient of their delusional world unless we understand the conditions in which they became necessary.

Sigmund Freud

This chapter will describe the psychological processes thought to underlie psychosis and how these approaches can assist our understanding and management of psychotic disorders. There is no single model for complex conditions and the main theoretical underpinnings and treatment approaches derived from psychodynamic, systemic and cognitive behavioural frames of reference will be outlined. Clinical examples will illustrate the application of these ideas in clinical care.

Psychodynamic Approaches to Psychosis

The madman is a waking dreamer.

Kant [1]

A psychodynamic approach to psychosis builds upon the following ideas:

  1. 1. Psychotic symptoms represent a return to psychological processes which are normal in infancy and childhood

  2. 2. The content of psychotic symptoms has meaning and expresses material from unconscious areas of the mind

  3. 3. Psychotic symptoms tend to be created by primary process mental activities, rather like dreams, so the meaning may be disguised

  4. 4. The personal biography of the patient provides material which may be key to understanding the presentation

  5. 5. Psychological mechanisms in psychotic functioning include projection of internal experiences into the outside world, a rupture in the contact with reality, denial, rationalisation and loss of the ability to symbolise leading to concrete thinking

  6. 6. Delusions and hallucinations may be an attempt to rebuild contact with external reality and to find meaning after a breakdown has occurred

  7. 7. There is a psychotic and non-psychotic part of the mind in us all, with potential to revert to more psychotic ways of mental functioning under conditions of psychic strain

  8. 8. Psychotic symptoms are common and are brought to the attention of services when they overwhelm the ability to function and behave within usual parameters

The origins and development of these concepts will be outlined in this chapter, which will also consider what can be learnt about the mind from the investigation of psychotic functioning. Clinical examples will be described to illustrate how a psychodynamic approach helps to understand patients presenting with psychosis and can assist in their management.

Freud and Psychosis

The ideas of the insane have more in common with ordinary human concerns than might seem the case at first. Seemingly normal behaviour may in fact be much more bizarre when examined closely.

Sigmund Freud [2]

One of the earliest psychoanalytic explorations of psychosis was based upon Freud’s study of the memoirs of Daniel Paul Schreber, a judge who had a florid psychotic breakdown [3]. Schreber recorded his experiences meticulously in his memoirs and Freud applied himself to studying his account of his complex delusional system and hallucinatory experiences. Freud’s ideas formed the foundations of early psychoanalytic explorations of psychosis.

Freud considered Schreber’s symptoms to be understandable, meaningful and linked to early childhood conflicts and anxieties, particularly in terms of his relationship with his father. Thus, his symptoms contained a ‘fragment of historical truth’ (see Chapter 2). He recognised powerful processes of projection in his delusional symptoms, and therefore how a more extreme version of normal psychological functioning was operating despite the highly bizarre nature of the beliefs and experiences. He saw Schreber’s experience of his own mind fragmenting as projected outside himself and transformed into the belief that it was the world itself that was collapsing. Freud was able to shed light on the meaning of the psychotic symptoms by realising they followed similar processes to dreams, and as conveying vital information, both about the underlying issues behind the development of the psychosis for Schreber, and also how the deeper strata of the mind operates.

Freud saw the ‘central catastrophe’ in psychosis as being the fragmentation of the mind and loss of contact with reality in response to becoming overwhelmed with anxiety. He described how loss of meaningful connection with the world precedes the development of delusions and hallucinations – an anxiety state which forewarns of psychosis and which we may refer to nowadays as delusional mood. Freud recognised how Schreber’s state of mind became calmer as his delusions intensified and attributed this phenomenon to the restoration of certainty and meaning provided by the psychotic symptoms. This provides an understanding of how the distress and agitation of some patients seems to decrease as their delusional world becomes more crystallised in their minds; as if the delusions provide an alternative reality which although distressing may be preferable to the reality which led to the original breakdown.

Thus, Freud set the scene for an approach to psychosis that seeks meaning in the symptoms. He saw psychosis as a response to an external reality which has become unbearable for a fragile mind to apprehend, and recognised delusion formation as an attempt to re-find meaning in a more tolerable form. Freud described the development of delusions as ‘like a patch where originally a rent had appeared in the ego’s relation to the external world’ [4]. In addition to the noise and tumult of the psychotic symptoms Freud also noted the presence of a sane aspect of the patient, acting like ‘a detached observer’ during psychotic illness.

Freud was writing over 100 years ago; psychological understanding has developed considerably since then and some of his conclusions have been challenged and modified. However, as the case below illustrates, his early and groundbreaking ideas continue to provide helpful insights into psychotic patients’ predicaments.

Verity was an inpatient with a relapse of a psychotic illness, diagnosed as schizoaffective disorder. Her children had been taken into foster care as she was unable to adequately look after them. As her mental state stabilised she became increasingly preoccupied with her family and an access visit was arranged. On the day of the visit she became very agitated, distressed and persecuted making demands on the staff about the terms upon which she was prepared to see the children, none of which were possible to meet. She then said she had pain due to all the cracked eggs in her ovaries and was too unwell to go ahead with the visit. She settled quietly in her bed showing no sign of any physical discomfort.

Verity’s belief that her eggs were ‘cracked’, a term also used to describe madness, could be seen as an expression of her anxiety that her children had been damaged by her illness. The symptom presents this in disguised form as it is too painful for her to consciously know. This is akin to how our dreams may represent deep fears, wishes and urges from the unconscious areas of the mind – rather like the Trojan horse they can enter the citadel of conscious thought only disguised as something else. As Verity’s delusional beliefs developed, meaning that the visit was cancelled, she became less distressed. In this way the psychotic symptom has provided a solution to the problem and also allowed it to be expressed, using displacement, into a more acceptable physical pain. She did not seek medical attention for the abdominal pain she describes, suggesting that she also knows this to not be an expression of a physical health problem and in this way remains in contact with reality; rather like knowing a dream is a dream.

In considering what the symptoms may mean staff can be encouraged to really listen to their patient’s experiences and to understand better the underlying difficulties. Management can then be offered which is more in keeping with these issues, as in this case when her key nurse talked to her quietly about how her children were doing, which Verity listened to intently. The psychosis becomes material to be heard and thought about rather than a symptom to be treated.

Freud’s ideas contributed the following main themes to the understanding of psychosis:

  1. 1. Delusions are seen as psychologically determined phenomena, based upon powerful projection into the external world of disturbing mental contents

  2. 2. The central catastrophe in psychosis is the initial loss of meaningful contact with reality and fragmentation of the mind under conditions of excessive stress

  3. 3. Delusions and hallucinations are secondary symptoms to the original breakdown and are attempts to reconstruct a new reality with meaning and structure after the old reality has been given up

  4. 4. In remodeling reality, psychological processes similar to the primary process activity of dreams are revealed, such as wish fulfilment, lack of notion of time, hallucinatory realisation of repressed desires, displacement and condensation

  5. 5. Psychotic symptoms, like dreams, convey important material towards understanding the patient and their underlying difficulties

Psychosis and Early Development

Humankind cannot bear too much reality.

T S Eliot [5]

If a primary feature of psychotic processes is a rupture in the relationship with reality, and the recreation of an alternative, the processes by which we learn about and come to terms with the world around us can provide important information about what happens when this falls apart in psychosis. Psychoanalytic ideas about early development and how a relationship with reality is forged and stabilised in the mind can provide a basis for understanding how this can unravel in later life.

We are not born with an understanding of ourselves, the external world and the boundary and relationship between the two. These have to be learnt and the earliest days of life outside the mother’s body present immediate challenges for the developing mind. The infant has to find a way to withstand, differentiate, organise and understand the bombardment of all his experiences, his internal sensations and urges and encounters with the external world and people in it, now he is outside the mother’s body. He also needs to manage and to make sense of the mother’s absences while in a state of helplessness and dependency upon her care to survive. The challenges and psychological processes of normal infancy and childhood shed light on some aspects of psychotic processes in later life if the relationship with reality breaks down in psychosis. Psychotic symptoms from a psychodynamic perspective are seen as the intrusion into adult life of developmentally early modes of mental functioning.

Paranoid-Schizoid Functioning and Unconscious Phantasy

In her recognition of the intensity of infantile emotional life, and her description of the paranoid-schizoid position, Melanie Klein observed how the processes of early emotional life have much in common with psychotic functioning [6]. She saw the activities and structures of the mind as being primarily relationship seeking, or object related. During infancy and childhood, the self is constantly engaged in imaginary processes of either doing something to another or being done to. These themes are often expressed in childhood play. The splitting processes of paranoid-schizoid functioning allow for an initial binary differentiation between good and bad. States of distress are attributed to the actions of harmful others, persecutory objects, whose intent is to cause the distress. These archaic malign objects contain all projected aspects of the infant’s aggression or rage and the self is imagined to hold only goodness. This is the world of primitive object relationships, of projected states of mind into others, of an imagined pain-free state constantly under threat from a malign other. Klein believed that unconscious phantasies such as these form the basic structures of the unconscious mind. She observed how the infant interprets his bodily sensations, appetites and instincts including aggression and libido in terms of relationships. There is an initial truth in this as all his experiences depend upon the response of another – hunger is because he has not been fed for example, and a pain in the stomach is given meaning as an intrusion by another who is intent on harm.

These early phantasies linger and continue to provide meaning in the depths of the mind, an unconscious populated by primitive object relations, the world of binary concrete splitting, acting upon and being done to, and a self who is undifferentiated from primitive good and bad figures. These primitive object relations continue to give meaning to our experiences in subliminal ways – comments such as ‘you will be the death of me’, or ‘you’re breaking my heart’ revealing how our ongoing meaning-making processes are built upon these primitive interpretations of a good self being acted upon by another’s harmful intent.

In psychosis, these early primitive object relations are brought to the foreground of consciousness and intrapsychic pain is transformed into a problem between the self and a persecutory other. The external world becomes dominated by projected elements of one’s own mind, in a similar way to the child’s conception of the world.

Giles, an isolated and troubled young man, had long-standing conflicts with his neighbours, in part due to his keeping antisocial hours and playing loud music. He developed a psychotic belief that his neighbours were harming him by leaking poison into his flat, which he renamed Nirvana, and he showed a complete disregard for any role on his part in the difficulties.

This illustrates the return to more primitive forms of object relating, with the idea of an entirely good self under threat by the harmful intents of another – hallmarks of paranoid-schizoid functioning. Giles’ own intrapsychic difficulties had been transformed into an interpersonal issue with the illusion his own self was Nirvana-like and beyond reproach. The splitting in the mind between good self in relation to a bad object has re-emerged and his symptoms resonate with early unconscious phantasies. In Giles’ mind the neighbours became the problem and his own troubled internal states have become a problem in the outside world.

Symbolisation and Psychosis

We need to be able to symbolise in order for there to be space between ourselves and our experiences, otherwise we are simply in them. The ability to form mental representations of our experiences is the basis of mentalization and thought. The infant needs to be able to develop mental representations of his mother in order to separate from a merged state with her and to develop a sense of himself and the other with boundaries between them. In early life, psychic experience is felt to be the entire reality, a world of ‘psychic equivalence’, concrete and absolute states [7]. Symbolisation allows for our experiences to have an as-if quality which distinguishes thoughts and feelings from concrete reality, allowing for example words to describe feeling bad rather than the world having become entirely bad.

The ability to symbolise is learnt through repeated experiences of nurture and attunement, in which the child’s experiences are gathered, named and understood. The screams of persecution from paranoid-schizoid states become modified into a calling out from a baby who is able to hold the mother in his mind and to wait. This is accompanied by an increasing sense of the workings of his own mind, of his own volition, agency and wishes. The infant’s sense of himself becomes less confused with the other as he develops the ability to use symbols and metaphors and to tolerate uncertainty and ambiguity. Hannah Segal [8] described how the concrete thinking which characterises psychosis is due to the loss of the ability to symbolise, meaning psychic reality is indistinguishable from external reality – she called this symbolic equation, a return to the concrete experiences of early life. The certainty which accompanies many psychotic states, and the loss of any ‘as-if’ mode of thinking, indicates the ability to symbolise has become compromised. Concrete functioning also affects the nature of the transference relationships meaning that a psychotic transference may develop and this can profoundly distort the nature of relationships. Seemingly random acts of aggression on inpatient units for example can illustrate how the other has become concretely equated with a bad feeling or thought.

Paul had a relapse of paranoid schizophrenia when his mother started a relationship with a new partner. After a period of agitation and tearfulness he developed the delusional belief that he was the son of a prophet. He became calmer as the delusion gathered form, stopped his medication and assaulted his distressed mother after accusing her of trying to brainwash him when she tried to persuade him otherwise. Any anxiety or feelings of loss had been projected into his mother whom he then had to vigorously defend himself against – reality and ordinary concern had become a threat to his delusional reality.

As Paul’s psychosis developed he believed concerned family members were trying to control his thoughts by telepathy. To his mind this was a concrete fact and he boarded up the windows and door of his flat to keep the brainwaves out. He smashed the potted plants his mother had given him as he believed them to be spying on him on his mother’s behalf and refused all contact with his key worker, deeming him the ‘Anti-Christ’. When treated with medication he still had some paranoid thoughts about his family and their intentions towards him but was able to see these as anxieties and suspicions; in a more psychotic state there was no thoughts representing an as-if position; he knew they were harmful and he had to concretely keep them out.

This case illustrates both Paul’s return to primitive object relations in which his own projected concern and distress was experienced as an attack from his mother, and also how, through concrete processes, the pots had become equated with her and had to be destroyed. His external environment had become populated by the fears and concerns of his own internal states, with the loss of the reality of his good connection with his mother and any notion of painful feelings of exclusion and rejection. His previously good relationship with his key worker had also been transformed through a concrete and psychotic transference, the key worker becoming identified with all that was bad.

Hallucinatory Wish Fulfilment

In early life, if distress levels are too high, or the containing function of another is insufficient, the baby may turn to alternative sources of comfort and versions of reality that he creates in his own mind – referred to as hallucinatory gratification. For example, a distressed and hungry baby who refuses the nipple may gain some temporary respite from sucking at his own finger. This is accompanied by the psychic experience of omnipotence, a turning away from another and an experience of being able to meet all his needs himself.

Under conditions of intense mental strain in adult life, the mind may again turn to its own devices and create an alternative universe as a solution to a frustrating, depriving or terrifying external world. This alternative reality may refute just the situation which has led to it; for example, the omnipotence of paranoid beliefs within which the patient is of central and undeniable importance, as opposed to a reality of social exclusion and isolation. These solutions may seem bizarre as they are provided by primary process, gratification-seeking mental activity, with their origins in the hallucinatory wish fulfilment activities of infancy.

Thus, through her description of paranoid-schizoid function, Klein came to understand psychosis as a state in which less developed forms of psychic functioning come to the fore. Extreme projection of the turbulent and disturbing contents of the mind are expelled into the outside world and experienced as reality, meaning that the patient is surrounded by tantalisation, threats and persecutors. The attribution of parts of one’s own mind to another leads to the loss of separation and boundaries between self and other, with fear of intrusion and control from outside. Extreme splitting into absolute states of good and bad means that relationships become distorted and bizarre, and a delusional world in which the patient is often omnipotent and of central importance may be created, guided by the principles of hallucinatory wish fulfilment. Vulnerability, loss, dependence, painful exclusions and rejections are made non-real as the psychotic mind replaces these ordinary concerns and turns towards the creations of their own mind, with delusional and less painful alternatives.

Kleinian Contributions to Understanding Psychosis

Melanie Klein and her colleagues contributed the following ideas towards understanding psychosis:

  1. 1. Emotional life in infancy is characterised by extreme projection, concrete thinking, splitting and confusion of internal and external states, processes also seen in psychosis

  2. 2. Psychotic processes originate from paranoid-schizoid functioning. Paranoid mechanisms, and psychotic object relationships and phantasies are likely to be returned to throughout life when triggered by excessive anxiety

  3. 3. Unconscious phantasy underlies every mental process, activity and symptom

  4. 4. The ability to symbolise is crucial in psychological development and concrete thinking is a hallmark of a failure of symbolisation

  5. 5. The development of an alternative reality, guided by hallucinatory wish fulfilment, is seen in early life and also in psychosis

Klein’s ideas developed the psychoanalytic model that psychotic processes are present in the psychological biographies of us all and were followed by a flowering of interest in both the psychoanalytic treatment of psychotic patients and developing the theoretical understanding of psychosis.

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 14 – Psychological Approaches to Psychosis
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