2013 - The tilt of psychosis

On the 3rd of May 2013 a large number of people gathered together in Kortenberg for the annual conference of the ISPS-network Netherlands/Flanders. The theme of this year’s conference was ‘The tilt of psychosis’.

The conference was opened by Dr. Ludi Van Bouwel, who started out by stating that people are more than just their brains. She emphasized the importance of always trying to understand psychosis. Nowadays it is known that each of us has the potential to have a psychotic break (just think of the work of prof. Jim Van Os); the important question is what it is exactly that causes such a break to occur.

In his lecture, Dr. Darian Leader stated that present-day psychiatry generally focuses too much on symptoms, causing us to lose sight of the underlying structure. He emphasized how a specific symptom (for example refusing to eat) can have a different meaning for different patients. In talking about psychosis Dr. Leader made a distinction between ‘being psychotic’ (having a psychotic structure) and ‘going psychotic’ (having a psychotic break). Following on from this he stressed the importance of trying to find out how it is that patients with a psychotic structure often manage to remain stable for long periods of time. He also made a distinction between primary and secondary symptoms of psychosis. According to him, the primary symptom of psychosis is an experience of fragmentation, of mental collapse. From this perspective delusions can be seen as a way of trying to give meaning to this experience, an attempt at self-cure. Dr. Leader sensitively illustrated these ideas through a clinical case. Starting from the clinical material he showed how therapy with psychotic patients should always be a question of discovering and respecting their own idiosyncratic solutions.

After Dr. Leader’s lecture 2 people shared their personal experiences with psychosis. First, Miguel Van Den Bedem vividly described the emergence of his psychosis and the struggle that ensued. What I mainly remember from his talk is that he did not regard his psychotic breaks as episodes of illness, but as confrontations between his inner life and our society, a society that doesn’t always seem to know how to deal with these things. He also expressed the desire to mean something to others, despite his limitations. Michel Mestrum spoke about the uneasiness towards psychic suffering that stills exists in our society. All too often it is associated with failure and weakness. I was very touched by one of the statements that he made: “psychotic people make the vulnerable present in our culture”. It made me reflect on the way in which our society deals with vulnerability. Do we make enough room for it or do we tend to relegate it to the realm of ‘abnormality’?

Next, Dr. Lucas Joos talked about his view on the residential treatment of patients with psychotic disorders. He rightly emphasized that this kind of treatment demands a great amount of creativity and dedication on the part of the caretaker. It impells us to questions ourselves time and again. Because the confrontation with psychosis can cause us to lose our own hold, it is important to have a frame of reference to hold on to, a ‘secure base’ from which we can explore and to which we can return ‘when the going gets tough’. Dr. Joos also expressed concern about the growing role of management thinking in contemporary psychiatric care. This kind of thinking can encourage feelings of alienation in patients and caretakers, which is exactly what we need to avoid when working with psychotic patients. He stressed the importance of creating opportunities for unexpected and meaningful encounters.

After Dr. Joos’ lecture we heard another personal experience, this time from the mother of a psychotic patient. She courageously recounted the story of her son’s psychosis; how he became increasingly chaotic and disorganized and ended up being diagnosed with schizophrenia. She talked about the confrontation with limitation and loss; her son not being able to live on his own, the serious and sometimes permanent side effects of antipsychotic drugs,… She ended up asking a very important question, which once again questioned the way in which our society deals with vulnerability: “is life only valuable when you can make yourself useful, when you’re not a burden to others?”.

Following this touching story there was a musical interlude by the music therapy students of the Leuven University College of Arts. They performed an improvisation in which they managed to evoke the ‘tilt of psychosis’ in a very vivid way. At first there was peace, calm, the silence before the storm. Then, suddenly, upheaval and confusion, psychosis breaking out in all its violence, performed with such intensity that I don’t think it left anyone in the audience unmoved. After this intensity abated we were confronted with sadness and sorrow, the psychic pain that often lies at the core of psychosis. For me this part of the improvisation evoked the idea of the search for a safe haven, a place where the pain of psychosis can be tolerated and contained.

Jan Van Camp started the afternoon program with a lecture about voices, more specifically about hearing voices that aren’t really ‘there’, that are not a part of consensual reality. He stated that this phenomenon isn’t the ‘perogative’ of the psychotic patient; it can happen to each one of us. He gave the example of the loss of a loved one. Even when the person in question is no longer there, we can sometimes still hear their voice, speaking to us, evoking their presence. Van Camp linked this to Freud’s theory of the two principles of psychic functioning. Early in life the young infant tries to cope with the absence of the maternal breast by ‘hallucinating’ it. This type of hallucination is usually abandoned with the emergence of the reality principle (or in Van Camp’s words: “the reality principle limits the pleasure of the hallucination”). In psychosis something seems to go wrong here. Van Camp explained this through Lacanian thinking; the psychotic patient has a lack of symbolic foundation. He tries to keep his head above water through suppletion, but this balance is often fragile, and disturbances can lead to a psychotic break.

Dr. Margreet De Pater emphasized the importance of being included in a social network. She quoted research stating that 75% of psychotic patients have always felt lonely, or started feeling lonely before their psychosis. Again we encounter the problem of alienation… She also stated that psychotic patients were often remarkably well-behaved children, and that they rarely went through a ‘no-phase’. This calls to mind the problem of identity formation in psychosis, and the importance of working in an identity-promoting way. Dr. De Pater then described how she put her ideas into practice through a family-focused treatment model that focuses on setting boundaries and encouraging autonomy.

Dr. Eric Thys spoke about the link between psychosis and creativity. He began by stating that we can never have direct contact with reality, and that our experience of our inner world and of external reality is in fact a construction. He pointed out that attributing things either to the self or to the outside world, which most people regard as a very self-evident mechanism, is not at all self-evident for psychotic patients. To illustrate this he used the phenomenon of thought insertion. The main point of Thys’ talk was that this fading of the boundaries between inner experience and external reality also seems to be related to creativity (which for me brought to mind Winnicott’s concept of transitional space). He stated that there does not seem to be a real difference between the creative aspects of psychosis and creativity in general. The question Dr. Thys put forward at the end of his lecture (and deliberately left unanswered) was if it might be possible that psychopathology is in fact the price humanity has to pay for creativity.

All in all this was a very inspiring day during which a lot of questions were raised that deserve further exploration and reflection. Some of the themes that stood out for me were the relationship between ‘normality’ and psychosis (is there a categorical difference or can we speak of a continuum?) and the problem of alienation in psychosis and the role our society plays in this. The personal stories that were told strongly reminded me of the importance of giving a voice to psychosis, or, in more general terms, of giving the vulnerable a rightful place within our society.

Yannick Houben

clinical psychologist and a psychoanalytic psychotherapist in training. He works at the University Psychiatric Centre KU Leuven in Kortenberg.