The schizophrenic person often functions at a level of symbolisation where the materials that he uses to represent and communicate include, as in a dream, actions, body parts and sensations, and the eliciting of feelings in the psychotherapist. As in a dream, he represents meanings by their opposites and condenses many meanings in one representation. Here’s the eighth and final 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.
Suppose you meet your patient a few times. He begins to call you between sessions or to send messages to you. Disaster is imminent. He has failed in this. He has failed in that. He cannot cope. He will never be able to cope. He must have medication. He cannot stay out of a hospital. (If he is in a hospital: he cannot get out of the hospital.) It is hopeless. He is helpless. He is overwhelmed. He provides you with the material. You make interpretations. You and he see how he takes revenge on his family, perhaps how he treats you as a member of the family. The interpretations have no effect. You encourage him. Complications in his life pile up, one thing leading to another in a downward spiral apparently nothing can stop. He will kill himself. You must do something. Under these circumstances, you may try to do something. Whatever it is, it doesn’t work. You try to do something else. It doesn’t work. You are increasingly anxious about him. You feel harried. The patient is getting more incoherent. You wonder if treatment with this patient is going to get anywhere. You begin to consider electroshock or the state hospital or transfer to another psychotherapist.
Suppose you do not respond by doing something. Suppose instead something like this happens. The patient comes in. He looks at you. He says, “You look angry.” You say, meaning it, “I am.” He, much surprised, asks, “Why?” You say meaning it, “The way you keep after me, intruding upon me, pressing me—you push me and push me and push me—until I can’t think. I don’t like not being able to think.” He says, “It’s funny you should say that. That’s just the way I’ve been feeling. My parents put so much pressure on me to do well at school, it gets so bad, I can’t think.” You realise with some surprise that the tone of voice in which he says this, the clarity and thoughtfulness of it, mean that you have actually translated at last what he has been trying to communicate in his language and that this translation has made possible a higher level of functioning to him. You ponder about the level of symbolisation at which he arouses feelings in you as a way of representing what he feels.
Perhaps you think about dreams, and how he might assign feelings to a figure in a dream to represent a meaning in that dream. But that means— you are uncomfortable when this occurs to you—that in a sense you have been a character in a kind of dream of his. Suppose at another time the patient begins to miss appointments. When you can, you make interpretations concerning his avoidance and perhaps what he tries to avoid. He agrees. He continues to miss appointments. If he is an inpatient, you send the nurse to get him. He comes late. He will only come if you send the nurse to get him. You begin to get fed up with that. You issue an ultimatum: you will no longer send for him. If he doesn’t come on his own, he will have to miss appointments. He doesn’t come on his own. Or, if he is an outpatient, you call him on the telephone. He does not answer. Next time he sees you, he tells you he was there; he knew it was you when the telephone rang; he did not want to answer. You think to yourself that schizophrenic patients are narcissistic and that it is impossible to establish a relationship with them. You wonder if treatment with this patient is going to get anywhere. You begin to consider electroshock or the state hospital or transfer to another psychotherapist.
Suppose you do not respond by doing something. Suppose instead something like this happens. He says, “I’m too afraid to come to the appointments, I feel you’re angry at me.” You do not reassure him. You say, somewhat snappishly, “So what if I am angry, or if you are, for that matter. That doesn’t mean we have to break up.” He says, “It’s funny you should say that. I’ve been worried that since I missed these appointments, maybe it’s no use and we should stop meeting.” You say, suddenly remembering a wish he expressed somewhat casually some time ago to see more of you, “Maybe it would be a good idea, if we can work it out, to have another appointment during the week. I think you could use it.” He says, sounding relieved, “I think I could.” He asks if he can make up the appointment he has just missed. You make another appointment with him. He begins to attend sessions regularly and on time. You ponder what it means that a patient who wants to see you more often communicates this by a representation of it in its opposite—coming less often—just as a meaning might be represented through a primary process by its opposite in a dream.
The schizophrenic person often functions at a level of symbolisation where the materials that he uses to represent and communicate include, as in a dream, actions, body parts and sensations, and the eliciting of feelings in the psychotherapist. As in a dream, he represents meanings by their opposites and condenses many meanings in one representation. I think it is possible that the grandiosity of the schizophrenic person may be understood as such a representation, rather than simply as a manifestation of his infatuation with himself. Characteristically, in work with schizophrenic patients, the psychotherapist finds himself invaded by strangely intense affects—moved in subtle ways, apparently by the patient, to respond in ways that are disagreeably alien to the psychotherapist’s usual notions about himself. Many times, these feelings and alien conceptions are representations of the patient’s feelings and conceptions. This experience is different from that with the usual transference when the psychotherapist is more stably and more recognizably used to represent someone in the patient’s life. Instead, the psychotherapist, working with the schizophrenic patient, may have the unpleasant sensation of being a figment of his patient’s mind, a figure in his patient’s dream, a twin image of the patient, a body the patient has entered to use in expressing himself. Similarly, the patient often represents through his actions and feelings how he sees the psychotherapist. That is, for the psychotherapist, like looking into a mirror, only half aware that he is doing so, and seeing what he cannot or does not want to recognise himself. At such moments, the psychotherapist may find he wants to shatter the mirror. He is unreasonably annoyed with what he imagines is the kind of person the patient is.
All of this is made very complicated by the unwitting tendency of the psychotherapist and others to assume that the schizophrenic patient is using words to represent meanings in the same way he and they do because the words sound the same and are even often strung together similarly. I think it is possible that the tenuous nature of the relationship with the schizophrenic patient has more to do with the psychotherapist’s (as well as others’) intolerance of the experience of the actual modes of representation and communication used by the schizophrenic person, and their subsequent withdrawal from him, than with his lack of interest in such relationships.
On the whole, I find schizophrenic persons interested in reality and in others, but rather expecting to be misunderstood by, or to put off, others, and therefore uneasy as a foreigner might be who worries that he cannot make himself understood to a tribe of cannibals he has stumbled across. If I feel a patient is a human being much like me, if I am moderately interested in working with him, and find him on occasion enjoyable to be around, chances are we will be able to work together. If I have phantasies—I include some theoretical notions here—indicating that I find the patient unusually strange, mysterious, attractive, wise, violent, wicked, saintly, large, or small, or I find myself taking a rather self-consciously professional stance, it is likely that I am worried by what he is representing and communicating, that I am working very hard to keep my distance, and that he will not find my withdrawal and aloofness, no matter how they are garbed, especially helpful; chances are we will probably not be able to work together. That, I should like to emphasise, is not necessarily because the patient has gone away from me or is not interested in reaching out and getting some reasonable care and understanding from someone.
There is one other thing you may notice about your schizophrenic patient. Each time he meets you, you may have a sense that he does not quite recognize you, that you have become a stranger to him since the last session, and that he has to set about somewhat laboriously to get to know you again. You will recognize after a while the various manoeuvres and movements he makes in order to become reacquainted; frequently, he may wait for you to say something or elicit some comment from you, perhaps through a question. Sometimes he may behave startlingly as though he has forgotten you completely—what you are like, what his experiences with you have been. You are suddenly an enemy. Apparently, between sessions, his image of you has altered—much for the worse, as far as you are concerned. This is, I think, not necessarily to be understood as the result of an abandonment of objects and their representations in favour of an excessive cathexis of the self-representation. It is not paradoxical that with this apparent easy forgetting of you goes a dread of being separated from you. What is important here is that at the patient’s level of organization and functioning, all symbolic representations, whether of self or object, are unstable. (You may recall Selma Fraiberg’s impressive studies of congenitally blind infants—the difficulty such infants have in creating a constant or stable symbolic representation of external objects, which can be evoked in the absence of the object; their apparent difficulty in believing that others or anything continues to exist when tactile contact with them or it is interrupted; their painful response to separation, when the other is felt suddenly to disappear from existence, unrecallable, into a nameless void.)
I think that much of the process of psychotherapy with schizophrenic persons may have to do not only with changes in the conceptions symbolized in self-representation and object-representations but as well with the form of such representations and an increasing capacity of the patient to create and maintain a stable self-representation and stable object-representations. I have noticed that when my patient is able to remember me from session to session, to evoke an image of me in my absence that is reasonably like me and neither distorted nor frightening, to miss me when we are apart and to greet me with recognition, he is usually at the same time also beginning to feel that he knows from day to day who he is and what self-continues through his experience. Then he is encouraged, and so am I.
I feel we have accomplished as much as we can for now. I am expressing my hope, as well as perhaps that of some of you if I say at this point not “this is the end,” but “to be continued when next we meet.”
©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’.