Abstract
Clinical work with patients who have psychotic illness is rewarding; however, it is also psychologically demanding. The more challenging side of this work is not often emphasised in routine psychiatric practice. There are powerful unconscious processes present in psychosis that have strong countertransference effects that need to be understood and worked with.
Introduction
Clinical work with patients who have psychotic illness is rewarding; however, it is also psychologically demanding. The more challenging side of this work is not often emphasised in routine psychiatric practice. There are powerful unconscious processes present in psychosis that have strong countertransference effects that need to be understood and worked with.
This chapter links with Chapter 14 and highlights relevant aspects of psychoanalytic theory. Case examples are used to illustrate the countertransference effects of this work, on individual clinicians, teams and the care organisation itself. Interventions that reduced the impact, alleviate the risks and improve clinical care will be recommended. The novel clinical material is drawn from the experience of the author as psychiatric consultant, and psychoanalyst. Most of the case examples are composites drawn from inpatient work where these experiences can be seen most distinctly: they will hopefully be recognisable to those working in frontline services.
Theory
The Psychotic versus the Non-psychotic Part of the Personality
Wilfred Bion, one of the first psychoanalysts to analyse individuals in a psychotic state, described a universal division or split in the mind that results in two parts to the personality. On one side is the healthy developmental ‘non-psychotic’ part which strives to cope with emotional pain, engage with life, grow and develop: this part is able to make contact with others and ask for help when it is needed. On the other side is the ‘psychotic’ part of the personality which hates reality, and mounts ‘sadistic attacks’ on the thinking process, fragmenting thoughts which are then projected into the outside world: this ‘psychotic part’ attacks any connection with others and any need for help [1]. Each part functions separately, has little awareness of the other and fights for dominance of the mind.
Roger Money-Kyrle, a psychoanalyst with a background in philosophy who was analysed by both Freud and Klein, developed these ideas further. He portrayed the two parts as two sides, a ‘sane side’ ‘painfully acquired’ during development, and a ‘chaotic side’. His opinion was that sanity may be ‘no more than an island … in a sea of chaos’ which throughout life continues to exist unconsciously. In those that developed a psychotic illness the ‘chaotic side’ has ascendency; however, the ‘sane side’ is still there and available for contact [2].
Richard Lucas, an adult psychiatrist and psychoanalyst already mentioned in Chapter 14 who worked as an inpatient psychiatric consultant at St Ann’s Hospital in North London, applied Bion’s ideas to the reality and the challenges of working with psychotic illness on the front line of mental health. In his influential and unique book The Psychotic Wavelength [3] published just before his death in 2008, Lucas states that our ‘normal’ or ‘neurotic’ sensitivities can be likened to being on ‘wavelength 1’, while the psychotic patient may be operating on an entirely different radio frequency, ‘wavelength 1,000’. If we want to be able to work effectively with patients suffering with psychotic illness we need to tune into ‘this psychotic wavelength’. To do this requires us to continually bear in mind the two separate parts of the personality as described by Bion. We need to ask ourselves which part we are being confronted by at any particular moment in time. Lucas warns that if we are not aware of this risk we are in danger of missing underlying psychosis. If we are mindful of this, it means that ‘there is always a part of the patient that we can talk to about the way that their psychotic part is operating’ [3]. He was a great proponent of the use of humour in clinical work. He gives a lovely example where he and his patient’s ‘non-psychotic’ part have a joke at the expense of ‘the psychotic part’.
My patient on admission said that he was God’s older brother, but smiled and joined me in the reflexive position when I said that he must have been really pissed off with his younger brother getting all the publicity.
In clinical settings the battle between the ‘psychotic’ or ‘sane’ versus the ‘non-psychotic’ or ‘chaotic’ is ongoing in staff and patients alike. Mutual and powerful projective processes go on all the time between both groups. The psychotic part of the staff’s mind can be projected, located and attributed to the patients and the sane part of the patients can likewise be projected into the staff. This give the impression that there is a clear division between the staff, who are entirely sane, and the patients who are seen as entirely mad. This is not the case and this perception can be a barrier to understanding the patients. Sane communications from the patients may then be missed or dismissed.
William was admitted for the first time to the ward shortly after his 75th birthday. He was unwell with a depressive psychotic illness. He had a delusional belief that he was dead. He repeatedly told the ward team that he had to go home to look after his dead mother. The ward team assumed that this was a delusional belief. One of the Occupational Therapist’s went with him to do a home visit and found a lady in her 90s living in an upstairs room.
This feeling of walking a tightrope between ‘psychosis’ and ‘non-psychosis’ is further heightened by the level of ‘psychotic’ or ‘primitive’ anxiety that is ever present in clinical teams. ‘Psychotic anxiety’ is a term initially used by Bion to describe the anxiety that accompanies the ego disintegration in psychosis. This anxiety results from the unconscious awareness of the fragmentation of the mind. It is more severe than ‘neurotic’ anxiety where the ego remains intact. This primal terror can lead to unpredictable desperate and destructive behaviour, such as suicide or violence. Staff working in this environment have to tolerate this ever-constant feeling of threat which heightens their tension, leaving them close to their own psychotic functioning.
Countertransference
The primitive and powerful defences used by the psychotic part of the mind – denial, projection, splitting and rationalisation – are ubiquitous from very early in life. They are easily activated and have a strong countertransference and controlling effect on the unwary clinician.
Lucas makes a very strong argument for those working with psychotic illness to be constantly aware that the commonest symptoms of psychosis are not hallucinations, delusions or first rank symptoms, but in over 95 per cent of cases, denial and rationalisation dominate. These defences are used by the ‘psychotic part’ of the mind to try ‘to cover up its murderousness’ [3, p. 142]. It is murderous because it wants to totally destroy the sane part of the mind.
The Clinicians
Particularly potent countertransference responses to a patient with a psychotic illness include:
1. Denying or disregarding the patient’s history
2. Accepting the rationalisation of the ‘psychotic’ part of the patient
3. Mental confusion
4. Concretisation of thinking
5. Overidentification with projected sadism
The risk of being overwhelmed increases if the clinician is seeing the patient for the first time, and/or on their own. Money-Kyrle said that enormous forces are used by the ‘chaotic’ part of the mind to ‘convert, pervert or override’ the threat of the ‘sane’ parts, not only of the patient themselves but also of others [2]. The risk of being overwhelmed is minimised when the clinician knows the patient and their history, and if a third person is present at the assessment. In this latter case each assessor can rely on the other to check the reality and likelihood of what they are being told and to take into consideration their countertransference responses.
Denying or Disregarding a Patient’s History
Diagnosis in psychiatry is a complex and conflictual area. A reliable diagnosis is generally determined over a significant period of time. Psychiatrists are currently trained to follow a psychiatric diagnostic hierarchy which forms the basis for classification systems such as the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual (DSM). Each level of the hierarchy needs to be ruled out before a diagnosis from a lower level can be confirmed. For example, an organic cause for illness needs to be ruled out before a psychotic illness can be diagnosed, a psychotic illness before a mood disorder and mood disorder before a personality disorder. A patient’s psychiatric history is also very important in reaching a diagnosis – what has happened before is likely to happen again. Delusions that have been present in the past tend to emerge in a similar form in each episode of illness. If there has been a serious psychotic illness in the past a recurrence cannot be ruled out.
The powerful projective countertransference effects of psychosis that overwhelm the clinician frequently result in the disregarding or denial of the psychiatric diagnostic hierarchy and the history of the patient.
Catherine was brought in with contractures of muscles in her hands and legs from lack of mobility over several months. She had been lying on her sofa not moving, she had very poor self-care, and recently had not been eating, drinking or washing. She had had a diagnosis of psychotic illness earlier in her life, with two episodes with clearly recorded psychotic symptoms. She had been seen by a locum consultant in an outpatient clinic. At the time she was taking antipsychotic medication, but the consultant felt very provoked, frustrated and irritated in the clinical interaction with her and as a result decided she had a personality disorder. He stopped her medication and changed the diagnosis on her records to borderline personality disorder. Over the next nine months, she deteriorated physically and mentally. She was seen by the community team and even though there was clear evidence of a profound decline it was repeatedly put down to ‘acting out’. No medication was given, and no admission offered. When Catherine was finally admitted she was close to death. She was started back on antipsychotic medication and recovered.
Although extreme, this scenario is seen frequently in a less severe form and illustrates how dangerous it can be when clinical management is powerfully influenced by unmetabolised countertransference reactions. The splitting, denial and rationalisation is projected, and a clinician who does not know the patient well changes the diagnosis due to their immediate countertransference experience. The history is discounted, and the psychotic diagnosis overwritten with a one lower in the hierarchy. The team can then become divided and entrenched diagnostically. Psychotic illness is higher up the psychiatric diagnostic hierarchy than a personality disorder. If psychosis cannot be ruled out it needs to be retained as a possibility. Personality disorder services can get frequent referrals of patients on high doses of antipsychotic medication with a clear history of psychosis over many years. It is also not uncommon for a very disturbed patient with a persistent diagnosis of personality disorder, who actually has an undiagnosed psychotic illness, to be admitted to an acute psychiatric ward and fully recover with antipsychotic medication.
Accepting the Rationalisation of the Psychotic Part of the Patient’s Mind
In the following case Helen, a medical student, met with Philip, a recent admission to the psychiatric inpatient ward, for an assessment on her own. She presented Philip’s history in the ward round to the team.
Helen seemed preoccupied and said she was puzzled as to why Philip was in hospital. Surely the ward staff should be more concerned with his neighbour who pursued him, listening to his every move, banging on the floor and walls wherever Philip was sitting so he had no peace. This neighbour would record him, Helen said, and would lie in wait to abuse him and tell him to kill himself when he left the flat. She said that Philip had discussed it with his mother, but he realised that she was conspiring with the neighbour. He said he had also tried reporting this to the police, but he became aware that they too were in this conspiracy. Helen asked why were the ward team not helping him get the appropriate prosecution started? As she was recounting this history out loud, she started to realise that the reality may not be quite as Philip had outlined it.
In this case Helen had been pulled into accepting the rationalising of the psychotic part of Philip and lost her own contact with reality. It was only when others were present, and she could see the doubt they expressed that she could reconnect. This experience is a frequent one because rationalisation is a very powerful defence. We often do not want to believe how unwell our patient is, or we may want to believe that they are getting better when they are not.
Mental Confusion
Another common countertransference response to psychotic illness is confusion. Lucas describes the reason for this:
The clinician’s countertransference feelings will mirror the patient’s state of mind. If they have projected feelings that they have experienced as totally unbearable and have murderously attacked, then the clinician’s mind will be affected so that he or she feels deskilled, unable to think or have constructive associations [3].
In the following case example, the psychotic attacks on mental linking that have resulted in Edith’s psychosis infiltrate the mind of Dr Ball, whose thoughts also lose coherence and fragment.
Dr Ball had returned from holiday refreshed and relaxed. His first job on returning to the ward was to review Edith a newly admitted patient. When he had been talking to her for a while, he realised he wasn’t able to concentrate. He tried to pull his thoughts together but struggled and within a very short space of time he had lost track again. He couldn’t remember the question he had asked, or quite grasp why Edith was saying what she was saying. This happened repeatedly. He found that his mind felt ‘fuzzy’ and he couldn’t remember why he was meeting with Edith in the first place. Once he left the room his thinking recovered.
Related posts:
Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations
Chapter 9 – Systemic Family Therapy
Chapter 10 – Cognitive Analytic Therapy (CAT):
Chapter 15 – Personality Disorder
Chapter 16 – Complex Post-traumatic Stress Disorder
Chapter 17 – Psychological Approaches to Medically Unexplained Symptoms
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