Psychotherapy Paradigms in Schizophrenia: Object-Representation is Part of the Patient – IV

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The object world that constitutes the obstacle is the object world as conceives it to be, his symbolic representations of it. Our manipulations of the object world do not necessarily affect his conceptions of it. A situation may be changed or he may be removed from it, but he carries his symbolic representations of reality and the processes by which these are created with him wherever he goes. When says, “My mother is inside me,” he means just that. He is not using a mere figure of speech. The object-representation of his mother to which he refers is inside him, part of him. Here’s the fourth part of the eight-part serialisation of Prof. Ashoka’s lecture, wherein he deals with the practical aspects of psychotherapy, in the weekly column, exclusively for Different Truths.

I left the well-house eager to learn. Everything had a name, and each name gave birth to a new thought. As we returned to the house every object which I touched seemed to quiver with life. That was because I saw everything with the strange, new that had come to me. I think that what is happening in this description, and what happens in psychotherapy, not only in response to particular interpretations but in response to the process itself, bear a profound resemblance, although I do not yet have the theoretical tools to articulate what it is.

Incidentally, I am reminded of the criticism of some of you and others of many psychiatrists for their interest in psychotherapy as a treatment modality, not only on the grounds of difficulties in making psychotherapy widely available or of our own inadequacies as psychotherapists in symbolising and communicating with those carrying on these activities in ways different from ourselves, but rather on the grounds that psychotherapy is culturally appropriate to the verbal middle-class but inapplicable to members of the so-called lower socioeconomic class who, so it is claimed, do not value words. For them, then, pills and advice.

I wonder if it does not occur to such that a scarcity of language resources is not simply a preferred but rather a serious handicap in living and that an inability to symbolise emotional, physiological, and sensory experience is not incidental to illness but may, in fact, doom an to it. When we psychiatrists are exhorted to use other culturally more appropriate methods than psychotherapy in treating the lower socioeconomic class citizen—to accept, to adjust, so to speak, to his level of functioning—are we being asked to abandon him to a life of sleepwalking in a twilight zone of quasi-consciousness, in which he must depend for relief of his pain solely upon the efficient manipulation of his body and his ? (The same objections, of course, have been raised about psychotherapy with the inarticulate adolescent, with the impulse-ridden patient who does rather than talks, with the schizophrenic person who supposedly cannot and does not want to communicate.)

Actually, of course, if you decide that the etiologic or pathogenic event is a frustration arising from obstacles to the patient’s actualisation of some conception of the desirable, and if you decide that a major obstacle is the recalcitrance of the object world, you may set about attempting to alter this unfavorable situation in which the patient finds himself. You may recommend that he enter a hospital, in hopes that he will find there a less inimical, a more congenial, milieu than that in which he finds himself. You may advise him to leave home, to enroll in school or to drop out of school, to divorce his wife, or to change his job. You may meet the patient together with his parents, siblings, wife, or children, seeking to modify these others or rather the system of interactions involving them all.

That I do not call such measures—directed to the object world— psychotherapy follows from my definition of psychotherapy. That such measures may be useful under particular circumstances (and the ability to recognise such circumstances is part of clinical ) no one can deny who is willing to acknowledge that nonsymbolic aspects of reality—that is, the conditions in which we exert effort to achieve ends—play a part in determining the outcome of such efforts. However, for the most part, in my experience, such measures even when useful fall far short of what is required.

The main reason for this is, of course, that the object world that constitutes the obstacle is the object world as the patient conceives it to be, his symbolic representations of it. Our manipulations of the object world do not necessarily affect his conceptions of it. A situation may be changed or he may be removed from it, but he carries his symbolic representations of reality and the processes by which these are created with him wherever he goes. When the patient says, as patients have often said to me, “My mother is inside me,” he means just that. He is not using a mere figure of speech. The object-representation of his mother to which he refers is inside him, part of him; it was formed long ago by a being that he was and is in some sense no longer; but it is still inside him and remains inside him whether the tired, old lady whom he recognises as mother now resembles it or not. We may induce him to pity this tired, old lady, if he does not already do so, by talking with them together, but that alone will not change his relationship to the terrifying, seductive image to which he is so attached or his propensity for conjuring it up again and again.

Now, by none of this do I mean to deny, for example, that the family life of the schizophrenic patient has actually been extraordinarily unpleasant and literally maddening. In fact, once I have acquired not a cursory but over months a detailed knowledge of a schizophrenic patient’s family life, of the kind Lidz and his colleagues have reported, I have never had any difficulty understanding why the patient is schizophrenic, never felt that under the circumstances, given who he was and who his parents were and who their parents were, he could have been other than schizophrenic, never felt called upon to postulate an organic defect to make explicable how anyone raised in such a home in such ways could possibly have become schizophrenic. My usual feeling, in fact, upon acquiring such knowledge has been to regard the alternative we call schizophrenia as probably the only one possible to the patient if he was to survive at all and even sometimes as the best of a number of dismal, and even hideous, other possibilities conceivably available to him. I have usually been moved to congratulate him in my mind for the feat of managing as well as he had. As a , as a psychiatrist, and perhaps—I do not know—especially having been trained by a Jew, I respect to man’s capacity to survive. Though the misshapen forms of his survival—the distracted, warped, and constricted self—may make us wince, may make us cry, may repel us, they also command respect.

(To be continued)
©Prof. Ashoka Jahnavi Prasad

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Ashoka Jahnavi Prasad is a physician /psychiatrist holding doctorates in pharmacology, history and philosophy plus a higher doctorate. He is also a qualified barrister and geneticist. He is a regular columnist in several newspapers, has published over 100 books and has been described by the Cambridge News as the ‘most educationally qualified in the world’.