The Psychodynamics of Psychosis, 2018
Martindale, B. & Summers, A.
Quotes:
“A core task of the non-psychotic adult mind is to integrate different aspects of reality, to tolerate conflict between them, to make compromises and to find ways of managing these multiple realities, often at the same time.”
“In the psychodynamic approach to psychosis, attention is paid to clarifying experiences of reality that the person has found unmanageable and which have, through the psychosis, been dispensed with or altered, rather than contained, ‘digested’ and integrated as in non-psychotic states. “
“....hallucinatory experiences and delusional ideas will contain clues to both the defensive processes in play and to the underlying realities being evaded….“
“Psychosis develops when current stresses outstrip the mind's capacity to cope through non-psychotic mechanisms.”
“The capacity to bear and process affects develops within attachment relationships as part of the development of the inner world. The capacity to mentalise is an important aspect of this.”
“A particular experience may be stressful either because it increases inner sources of insecurity and anxiety and arouses unwelcome affects, or because it interferes with defences that have protected against these.”
“...understanding the personal stressors that particularly affect an individual will assist relapse prevention.”
Thoughts:
I adore this paper. I do want to make sure to point out though that many clients experiencing altered states will entirely disagree so that deserves to be highlighted. This makes it more difficult to offer this view as an all encompassing theory due to my own hesitation to imply that all people can be defined in the same way. Especially since it feels insulting to tell someone about their perspective.
I so often talk about avoidance but denial is a slightly adjacent idea. So interesting. Also it makes me think of anosognosia (the term for when a person doesn’t identify or agree that they have a disorder or problem). The term denial seems to contribute to an active stance instead of with avoidance that can often feel to me as passive turning away from (even though turning away is still active, just maybe doesn’t feel like action or a choice).
I find the idea of projective identification very helpful in therapists understanding how they feel after and between sessions. It is not uncommon at all to leave a meeting with a feeling that is difficult initially to put into words but the feeling is poignant and can be so helpful in understanding our client.
“Attacks on linking” is something I’m always so excited about when it shows up in our discussion. It’s that linking puzzle piece that had been missing until they share that comment. Such a great feeling.
“However, unravelling the individual's experiences and internal life may not be easy, as the psychotic processes themselves may inhibit the individual's attempts to reflect on the meaning.” This one resonates with me a lot. I often think of the similarity of the defense and a living organism that is trying to survive. It will shift to protect itself. Makes sense as defense mechanisms are survival strategies to get through. (Not implying anyone going through altered states actually has an organism inside of them. Just the parallel of self-protection).
“There is evidence now that people who develop psychosis are more likely to have experienced trauma (citation), to have developed insecure styles of attachment and problems in mentalising (citation)” And these references they are talking about are from 2008 and 2010! Dang if these had been able to be more widespread at the time. I’ve been reading about this stuff for literally 20 years now and it is finally now being more accessible on a wide scale. So cool.
“Some individuals with psychosis break down when struggling to achieve a separate sexual identity, with the disentangling of the physical and emotional attachment to one or both of their parents. Others may have experienced sexual abuse that seriously complicates this development. Actual separation from home is a further major challenge.” This experience feels to me like it comes up so often in working with altered states. I often phrase it to myself as an inability to individuate and wonder about aspects of competition or rejection from the role models to the person or of the person rejecting the role models.
“Psychosis not infrequently seems to develop in the context of powerful feelings of aggression, and of inadequate non-psychotic strategies for managing these.” The ability to bear anger and have an outlet for it that can be conscious is so important.
“In the earlier stages of the lives of certain young men, their cultural environment supports the development of relationships where violence is encouraged and is felt to be relatively unproblematic. When the cultural context changes, there may be a very stressful misfit between their inner and outer world, contributing to psychotic breakdown.” This is such an excellent point. Something that was allowed and even praised now becomes unacceptable or threatens the relationship. Such a feeling of having the rug ripped out from under us. Also if we can not bear anger towards those who taught us that it was ok, who we might feel set us up to be hurt, then we have to look away from it even more.
This article is so wonderful. It has so many facets that I often talk about and it’s seriously so validating to hear them all in together. And still multiple times during the reading I completely lost my focus and got just lost and confused in it. All part of the process :-)
Discussion topics:
Have you come across these concepts in your involvement with treatment for altered states?
Do you feel your providers would be open to this article or potentially respond by using some of the defenses if offered to read it? Which ones do you think would come up for them? What about family?
Did you notice any defense mechanisms that you frequently go through? Does reading about them feel uncomfortable? Can you be kind to yourself and remember that we are all human and these are common responses to discomfort?
Look ups:
I would really recommend looking up Wilfred Bion’s work.