Psychotherapy Paradigms in Schizophrenia: Recovering Distorted and Damaged Images – I

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This experience is much different from the difficulty the schizophrenic patient has in retaining from one session to another an image of the psychotherapist in his mind to whom he can speak. Following each session, this image slips away, is damaged, and is distorted. Over and over again, this image must be recovered and repaired if the patient is to return and, returning, be able to speak again with the psychotherapist. Here’s the first 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.

When I started writing, I conjured up in my mind’s eye an ideal readership. Every line I wrote was received with just the sympathy, the smile, the friendly twinkle, the understanding, the rush of pleasure it called for. With each such response from that ideal student and colleague in my mind, the words came rushing with exhilaration to my pen. Despite my efforts to insulate myself from the reality of your response, word reached me of it. Instead of one ideal companion of the intellect, I was forced to become aware of all the different “you’s” out there, with different backgrounds, needs, preferences, speaking different languages (not all of them mine and mine a stranger to many) and suffering different anxieties. No one with whom I could speak—and if I chose any with whom to speak, I now watched with my mind’s eye another turn away.

The preparation of this article (read lecture) was much more difficult than that of the previous ones, went more slowly, and took more effort. Some element of that strain I blame on the effort I was forced to exert to reconstitute painfully the image of my companion of the intellect in my mind so that I could write again.

I do not think this experience much different from the difficulty the schizophrenic patient has in retaining from one session to another an image of the psychotherapist in his mind to whom he can speak. Following each session, this image slips away, is damaged, and is distorted. Over and over again, this image must be recovered and repaired if the patient is to return and, returning, be able to speak again with the psychotherapist.

As a matter of fact, changes in the representation of the therapist are important to an understanding of the process of psychotherapy with any patient, no matter what the nature of his illness. Changes in the internalised image of the therapist determine much that is puzzling in psychotherapy—inexplicable and often abrupt alterations in ambience from one session to another; sudden difficulties in communication—and are important in evaluating the direction and outcome of psychotherapy. Similar problems (the mystery of creativity; the vicissitudes of, including inhibitions or blocks in, creative work) are also clarified by reference to changes in images of listening or looking objects imagined within or—of ultimate significance in both creative work and mental illness—in images of the self as listener or looker. Ultimately, it is from the self in its function as superego that the creative worker receives permission to carry out one intention rather than another, to wait for a conception to realise itself, to move from one type of symbolic process to another, to pass freely from one level of organisation or consciousness to another. The self, imagined by the schizophrenic patient, offers no similar consent. It is this difference that makes the creative worker in his functioning relatively independent of actual interpersonal relations, and the schizophrenic patient in his functioning, despite his apparent aloofness, so dependent upon and reactive to them.

Can we avoid succumbing either to a shallow environmentalism, with its wishful optimism, or a fatalistic physicalism with its invitation to operate upon the patient as an object? Is not the aim of psychotherapy to enable the patient to beget a new self-representation, not simply by providing him with beneficent “interpersonal experiences” that teach him an altered conception of himself, but by requiring him to articulate, to form, to use new materials in representing, his self-conception so that in giving it new shape at a higher level of consciousness he both discovers and creates it? One difficulty with Freud’s early notion of “the Unconscious” as a system, particularly in conjunction with his archaeological metaphors, was the implication that conceptions lie finished but buried in that system waiting to be dug up, rather than—as Freud’s metaphor of the patient in psychoanalysis who is a sculptor uncovering the self that waits to be revealed in marble stone instead implies—that conceptions of self-are discovered through their creation, in the medium not of marble but, for example, first of the materials of the transference neurosis, and, ultimately, of language. This process begins when in treatment the patient is required to symbolise the conceptions represented by his symptoms in another medium. But I have taken another detour into speculation. Let us return to imagining the schizophrenic patient experiencing such states as these you and I have experienced here, not for brief moments, but over and over and for long periods of time. Imagine even greater drops in the level of functioning, occurring perhaps with catastrophic suddenness. Imagine such a patient attempting, slowly, painfully, with diminished capacity, to recover from such losses of level, only to fall back repeatedly, because he is even more vulnerable to such losses of level at lower levels of functioning, losing hope, losing confidence that recovery can ever be achieved or, once achieved, that it can be maintained.

(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’.