As human beings we are constantly making sense of our world. Sometimes the conclusions we come to are frightening, and sometimes we’re mistaken. Sometimes we see or hear things that aren’t there. Sometimes our judgements are affected by our past experiences – if we’ve survived bullying, abuse or racism, for example, it might be difficult to trust people and we might understandably become a bit paranoid. Sometimes – for example when we’ve drunk alcohol or taken drugs, or sometimes even when we haven’t – the way our brain is functioning can affect our judgement. But in each case, we are actively making sense of our world. Recent research into ‘psychotic’ experiences has found that often this sense-making or interpretation of events (‘cognitive factors’ in technical language) can play an important role.
(From Understanding Psychosis and Schizophrenia published by the British Psychological Society – page 47)
The Purpose of Psychosis
Longden and Read’s thorough exploration of the relationship between psychosis and trauma, which was the focus of my last post, paves the way for a crucial insight, which currently carries too little weight with professionals dizzy from spending too long going round in psychiatric circles (page 10): ‘the conceptualisation of the psychological aftermath of adversity (including complex experiences like hearing voices, or extremely paranoid beliefs) as a meaningful way of responding to, or coping with, distressing and overwhelming events.’
This idea we have already met in my earlier post on out-of-the-ordinary experiences (OOEs). Charles Herriot-Maitland et al contend that there seems to be some direct relevance of OOEs to the context of participants’ existential questioning. From this, it could be interpreted that the OOE actually emerged as a direct expression of, or indeed solution to, some kind of psychological crisis.’
To build on this understanding and to place it in a more ‘normal’ context to reinforce that psychotic experience may simply be at one end of a normal continuum, I want to pick up on my work with Laura again, the lady who thought that her mother had thrown her away the day she was born. Admittedly her diagnosis was endogenous depression (ie deep sadness with no obvious cause), but that may not rule out any relevance to our current concerns as we will see.
She initially had no sense that life had given her any reason to be depressed. She was an articulate lady who gave clear descriptions of her history, which included a basically contented childhood, and of her current feelings, which were often suicidal, though she did not understand why.
However, some part of her mind knew perfectly well where the problem really lay and recognized its exact nature. This awareness broke through in the metaphorical form of her dreams, a psychotic experience we all share at night whether we remember them or not.
One day, she spoke of a recurrent dream she was having. With variations, it was of being in a room with Hitler’s SS. They wanted information from her and were preparing to torture her. Before the torture could begin she invariably woke in terror. Following the model I used for my own dreams I asked her to give me a full description of every aspect of her situation in the dream. She described not only the people, but also the size and shape of the room and the kind of furniture that was in it.
Naturally, we focused at first on the people, but, apart from the obvious link of her having been brought up in the aftermath of World War Two, there were no links with the SS officers who were threatening her. The room did not trigger any useful insights either. We were beginning to wonder whether this was simply a childhood nightmare of the war come back to haunt her, when I asked about her associations to the furniture. We were both instantly shocked by her first answer. It was exactly the same as the furniture in the kitchen of the house in which she had grown up.
It would not be right for me to go into any detail about where this led. I imagine everyone can see that the picture she had persuaded herself was real, of a contented childhood, was very wide of the mark. That she had no vivid memory of any one dramatically traumatic incident was because there were none to remember: her whole childhood, as we then gradually came to understand it, had been a subtle form of emotional starvation and neglect successfully disguised for her at least as normal parenting.
The key point for present purposes is that the bizarre and frightening dream contained a vital key to her greater self-understanding. My question is, ‘Why cannot a psychotic experience be the same?’ There may be reasons in terms of brain deficits why terrifying leaks from the subliminal mind create a waking dream, but there is evidence that such deficits are the result of the underlying trauma itself, as we have seen in the discussion of damage to the lateral prefrontal cortex, which can no longer act as an effective filter.
Many other people have been struggling to articulate similar perspectives.
Shields, for example, in his paper Psychosis as Coping, which I referred to earlier in the discussion of drugs, makes a similar case (page 143):
This paper proposes that . . . . one sees psychotic episodes for what they may be: a mechanism for coping with existential distress – a way of being that allows an individual to escape existential realities when that individual cannot avoid these things otherwise. . . . .
Escaping the Intolerable
He goes on to clarify what he means (page 145):
. . . if existential distress becomes unavoidable but unmanageable . . . . a psychotic episode can function as a dissociative mechanism for avoiding that distress.
My own work over 35 years confirms this perspective. In 1988 a young woman persuaded her GP to refer her to me. She had carried a diagnosis of schizophrenia since she was 16. Before that she had had a twelve year history of sexual abuse at the hands of her father which went undisclosed and unnoticed at the time. She wanted to talk about the abuse to someone. An OT and I saw her together, with some trepidation. After all, psychosis and psychotherapy weren’t supposed to mix in those days. I’m not sure yet how different it is now.
I allayed my fears with an article that argued that, although ‘schizophrenia,’ a label that is increasingly questioned nowadays, was not in itself amenable to a `talking cure’, people with this diagnosis could benefit from counselling for other problems. We plunged in.
It took more than a year for her to begin to describe the abuse, so painful was it for her. She could focus on it for no more than ten minutes in each hour at first. After that she became overwhelmed with terrifying hallucinations of her father, hallucinations which impinged upon all her senses – smell, touch, hearing, taste and vision. The only way she learned to determine afterwards that he had not really been there was to observe that she had no marks upon her body. Generally it would take the rest of the session to help her regain control of her own mind.
As the months went by she could bear to reveal more of her painful story, though always in small instalments. Her fears about telling it diminished, but she still had not really come to terms with the emotional pain and the anger. For reasons of confidentiality I cannot share any of the particulars of her story. She was able, eventually, to break free of an abusive marriage. She gained greater control over other hallucinations.
However, one day, as our work continued and she became gradually more able to tolerate working on the memories, she was readmitted back into hospital. When I next met with her she explained what had happened.
She had ended up in a place that reminded her of one of the worst experiences of abuse. She was overwhelmed by all the original pain and terror. In my jargon, she had been re-traumatised.
We discussed her options. She could either remain in hospital on high doses of medication until the impact of this faded, or she could move to a residential facility with the close support of staff she trusted to work on these feelings and memories with the minimum of medication. She thought about this as she sat there, her eyes full of tears on the edge of uncontrollable sobbing. She chose to stay in hospital rather than have to face these feelings anymore.
In the next post I will be looking at where all this leaves us.