Psychoanalysis and schizophrenia

The New York Times recently published a fascinating article by Christopher Bollas in which he describes a five year analysis with a woman whom he calls Lucy and who has a diagnosis of schizophrenia.  What’s particularly interesting about this case is that Lucy lives on a remote island in a Norwegian fjord, and Bollas lives in North Dakota.  The analysis took place five times a week at 8pm and was conducted exclusively by telephone.

Another interesting point about this case is that Forbes ran a piece by Todd Essig, a clinical psychologist and psychoanalyst, which essentially trashed Bollas’ article.  Essig took particular exception to the fact that Bollas was conducting ‘remote therapy’ with a psychotic patient, and the fact that, in his view at least, Bollas seemed to be dismissing the role of medication in such cases.  Both articles focus on a particular incident when Lucy is confronted by a hallucinatory dragon for 30 minutes who tries to kill her.  Bollas links this to an earlier part of the conversation when he remarks to Lucy that it was good that of late her bad memories were not ‘dragging on’.  Although Lucy was able to work through this crisis, with the support of Bollas, for Essig this is just further proof that ‘remote’ therapy/analysis is not a good idea with this type of patient, and also that this would never have happened in the first place if she had been on medication.

But what I think is really interesting about this article is the fact that both Bollas and Essig acknowledge that psychoanalysis can be used with people who have a diagnosis of schizophrenia, i.e. who are psychotic.  Where they differ is regarding how such a treatment should actually be conducted.   Not that all mental health professionals would agree, and even Freud himself was of the opinion that psychoanalysis was not an effective treatment for psychotic patients.  However, there is a longstanding tradition within psychoanalysis of working with psychotic patients, and this is very much central to the work of those analysts practicing within the Lacanian tradition.

The term ‘schizophrenia’ was originally coined by Eugen Bleuler in 1908 and comes from the Greek skhizein (to split) and phren (mind).   In many ways this is a somewhat unfortunately choice because the term ‘schizophrenia’ would appear to mean ‘split mind’; this is unfortunate because it sometimes gets confused with ‘split personality’ or ‘dissociative disorder’.  However, the ‘split’ in schizophrenia is more of a fragmentation of the self, rather than the appearance of multiple ‘selves’ or egos.

Schizophrenia is often regarded in the psychiatric literature as one of the most serious mental illnesses.  In recent times it has also had a rather bad press, with lurid stories of ‘deranged schizophrenics’ discharged from hospital by irresponsible mental health professionals before going on a killing spree.  The reality is very different, and the schizophrenic individual is far more likely to kill or harm themselves than anyone else.

In the heyday of anti-psychiatry, i.e. the late 1960s and 1970s, the schizophrenic became something of an anti-hero and a radical non-conformist to the norms of ‘civilised’ and capitalist society.  Unfortunately this helped fuel something of a backlash in mainstream psychiatry, with a resurgence of a positivistic ideology and the idea that schizophrenia could be explained almost exclusively in terms of neurobiology and genetics.  Not that some of the key ideas of anti-psychiatry have disappeared; on the contrary they are alive and well, for example in the Hearing Voices movement.

One of the key ideas that came out of that period was that there was something meaningful in the experience of the schizophrenic subject, although in fact this was more of a revival of an older and largely forgotten tradition within psychiatry.  The ideas of Ronald Laing, expressed most eloquently in his book The Divided Self,  in particular championed the notion that the schizophrenic individual had something important to tell us – if only we had ears to listen.1

And this idea that the schizophrenic individual has something important to say is the key element of any psychoanalytical treatment of schizophrenia.  In other words, the analyst takes the experience of the patient as meaningful, in some way, to the individual, even if this experience includes hallucinations, novel constructions of language, a whole range of somatic symptoms, and various delusory states.

One of the real problems for the schizophrenic subject is that they feel alienated from the rest of the world, that no one understands them, that everyone just thinks they are crazy and talking gibberish.  And this is often reinforced by others who come into contact with the individual, including, unfortunately, some mental health professionals.  They simply do not have the patience, the time or the understanding to sit and listen to the person, to hear what they are trying to say about their experience of being in the world.

In the psychoanalytic relationship, on the other hand, the individual is given the time and the space to articulate, to speak about, their experiences, however strange they may appear to most other people.  The key question, of course, is what exactly is the schizophrenic individual trying to tell us……?

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  1. R.D. Laing. The Divided Self:  An Existential Study in Sanity and Madness. London: Penguin Books, 1990. []