It is certainly possible to recognise a patient’s pain and to let him know you recognise it: that is a great deal! It is not necessary to try to make the pain go away or to promise that it will. In fact, nothing is so destructive to a relationship with a patient as the implicit or explicit communication, in words or actions, of promises that can never be kept. Here’s the sixth part of the eight-part serialisation of Prof. Ashoka’s erudite lecture, wherein he deals with a case study, in the weekly column. A Different Truths exclusive.
That the quality of the relationship between psychotherapist and patient is crucial for changes in the patient’s capacity to symbolise and to achieve higher levels of organization and functioning and for changes in the form and content of his conceptions of himself and others I have no doubt. That this quality has anything to do with the psychotherapist’s intention to make up for deficiencies in the patient’s life or to provide him with opportunities for gratification in the therapeutic relationship I very much doubt.
I once was grandiose enough to offer something like that in the way, I thought, of comfort in a trying time and the patient about whom I have spoken to you let me know immediately and unmistakably, with more anger than I usually care to be exposed to, that treating someone like a child who can be distracted from grief with “candy” is insulting as well as useless.
I would have thought that if there is anything I have learned from this patient, and from others as well, it is that “you can’t go home again,” and that, in the words of the song, “you’ve got to cross that lonely valley by yourself.” It is certainly possible to recognise a patient’s pain and to let him know you recognise it: that is a great deal! It is not necessary to try to make the pain go away or to promise that it will. In fact, nothing is so destructive to a relationship with a patient as the implicit or explicit communication, in words or actions, of promises that can never be kept. There is no way to make up for a patient for anything he has missed or that he misses. There is no starting all over again and giving the patient the childhood, or being the mother or father, you or he phantasy he should have had.
Yet I am troubled about saying any of this to you because the matter is so complex that I am sure I have said something in these few words that can be easily misunderstood. I am also troubled because of some of my own teachers, whose clinical and personal wisdom I respect. Sometimes seem to me to be saying that there can be a new beginning for a patient in psychotherapy, that he can find in this relationship what he missed as an infant, that it is possible to go home again. It is likely I have misunderstood them. Or perhaps there is something in all this that future patients will help me to understand better.
To come back to your patient. I think it may matter a great deal to the future of your work with him whether you regard the morbid process in which he is entangled as, on the one hand, a narcissistic regression, a hypercathexis of the self, in response to frustration, or, on the other hand, an impoverishment or depletion of the capacity of the personality system to achieve, to maintain, or having lost it, to regain a higher level of organization or functioning, in response to the impact of an object world that does not support symbolisation processes.
I think we have to be careful how we characterise this object world. It is not, I think, an adequate formulation to say that the schizophrenic person has not learned to be rational or, conversely, has learned to be irrational in experiences with the object world. A few sessions with your schizophrenic patient may convince you that these formulations are inadequate. He might astonish and perplex you by coming in one day with eyes alight and clear voice to discuss relations between the characters and issues in the works, say, of Dostoevsky and Conrad, or, for that matter, the relations between his parents or between them and him or between you and him, with a degree of subtlety, cogency, articulateness, and insight you would be hard put to discover in your colleagues; perhaps the very next day he will stare at you blankly, yawn, mutter, and, with a poverty of language that is remarkable given the sophisticated vocabulary of yesterday, struggle to put the simplest words together. It is as if both of you peer at each other through a glass darkly; the inordinate sense of effort that you will experience at such moments even to see your patient, and I mean this literally, unclouded and without perceptual distortions, much less to keep on talking with him is, in my experience, pathognomonic of the presence of schizophrenia.
It is the stability of higher-level functioning that is at issue, not merely its presence or absence. The patient does not have the same success we do in passing from one level of functioning to another, up or down, voluntarily, and according to changes in the demands on him. His drops in level are relatively abrupt and catastrophic in extent, and they are experienced by him as outside his voluntary control—thus, the uncanniness and terror of schizophrenic states. Prolonged effort must be expended to recover from such drops. Such efforts at recovery—which we often have difficulty recognizing as such in the symptomatology, behaviour, and communications of the schizophrenic person are precariously maintained, yielding with relative ease upon impact with new drops in the level of functioning. Different forms of schizophrenia are probably related, then, to the forms that such efforts at recovery take, the amount and persistence of the effort, and the degree and stability of the success achieved.
What is the contribution of the object world to this state of affairs? The object world may not provide resources or incentives required for a higher level organisation or functioning or it may be, in a variety of ways, positively disruptive of such higher level organisation or functioning.
(To be continued)
Prof. Ashoka Jahnavi Prasad
Photos from the Internet
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