Living with Psychosis Paula Conway & Andreas Ginkell a psychodynamic development model of psychosis and its psychosocial application ISPS UK October 2012

Living with PsychosisPaula Conway & Andreas Ginkell

a psychodynamic development model of psychosis

and its psychosocial application

ISPS UKOctober 2012

Every professional, as well as every relative or carer, has experienced the frequent and specific difficulties that people affected by psychosis have with engaging in or interacting in relationships.

This includes anxieties about personal, social contact and difficulties in interpreting the intentions of others, characteristically leading to withdrawal.

These difficulties in social interaction experienced by people living with psychosis pose a dilemma, as treatment and support inevitably require relating and social interaction.

Living with Psychosis

In our presentation today we are proposing that these difficulties in relating and socially interacting, which are characteristically affecting people living with psychosis, are due to developmentally established psychosocial disability.

The nature, origin and expression of this psychosocial disability becomes specifically visible from a psychodynamic point of view


provide a model and language for addressing the specific psychosocial difficulties experienced by people living with psychosis

make psychosocial disability more visible and its consequences predictable

provide a pragmatic guide to supporting the psychosocial needs of people living with psychosis and furthering their recovery and social inclusion

The psychodynamic development model of psychosis formulates this view and aims to:


positive symptoms

negative symptomspsychosocial dysfunction

social withdrawalprodromal / remission

acute episodes

psychosocial disability


The psychosocial disability underlying psychosis is an

inherent risk of the specifically human processes of

development and maturation of the human ‘social brain’.

The psychodynamic development model proposes that:


Evolution has resulted in human babies being born extraordinarily immature and absolutely helpless.

Brain growth and structural development are accelerated after birth and continue well into early adulthood.

Brain / neuro development is responsive to environmental, i.e. social interaction.

The human brain is a ‘social brain’ = mind.

The evolved human maturational processes


D.W.Winncott observed and described in psychodynamic terms the experiential processes of this evolved human maturation.

omnipotence

mother – baby unit

mother has objective omnipotence – baby has ‘subjective’ illusion of omnipotence

The psychodynamics of the evolved human maturational processes

phase of total helplessness - absolute dependence on maternal care – there is no such thing as a ‘baby’

baby’s primary narcissistic omnipotence


good parts / experiences

states of mind

bad parts / experiences

states of mind

mother – baby / infant unitabsolute dependency on maternal care

primary narcissistic omnipotence

PARANOID / SCHIZOID POSITION

annihilation / persecutory anxiety

splitting / projective identification

I


good parts / experiences

states of mind

bad parts / experiences

states of mind

mother – baby / infant unitabsolute dependency on maternal care





I

sheme

beginning of me / not-me differentiationabsolute dependence on maternal care

subjective omnipotence

birth of subjectivity


Subjective Triangulation

•

I

sheme

subject – object differentiation / Subjective Triangulationrelative dependence on maternal caresubjective – objective omnipotence


Subjective Triangulation forms the basis for Oedipal Triangulation

I

sheher

memyself

other

herself

she I

she is also an

I

Is the other in her mind me? -

She has also a mind

like mine

I am another !I am competing with

others for this place in her mind

self object

subject

subject


memy

her

his / her

I other

she herI

other’s Ihis / her other

Oedipal Triangulation forms the basis for Social Interaction


memy

her

his / her

I other

she

DEPRESSIVE POSITION

depressive anxiety

repression

desire / guilt

= identified


All relationships, social interactions are inescapably not just between two people! Every relationship is inherently affected by a third element – the other!


memy

her

his / her

I other

she

DEPRESSIVE POSITION

depressive anxiety

repression

desire / guilt

= identified


A person’s ability to process the emotional challenges of oedipally structured social life in the depressive position constitutes an ordinary good outcome of early development and socialisation



However, how does a person who operates from a

paranoid schizoid position cope with social life?



I other

her

his / her

memy

sheprimary narcissistic

omnipotence

= persecutor




Idealised=


memy

her

his / her

I other

she

= identified


Oscillation between functioning in the Depressive Position and operating in the Paranoid Schizoid Position does happen.

DEPRESSIVE POSITION



I other

her

his / her

memy

sheprimary narcissistic

omnipotence

= persecutor

Idealised=

PARANOID SCHIZOID POSITION


memy

her

his / her

I other

she

= identified


DEPRESSIVE POSITION


Why do some people ‘interact’ with life more than others

in the paranoid schizoid position?


omnipotence

mother – baby unit

The foundations for the functional structure for the psychosocial mind are based in the

earliest relationship with mother and how the baby’s omnipotent needs were met.


ID


MOTHER / OBJECT

subjective omnipotence objective omnipotencesecondary narcissistic omnipotence

EGO SUPEREGOPSYCHOTIC PART

Developmental Origins of the Psychodynamic Functional Structure of Mind



I other

her

his / her

memy

sheprimary

narcissistic omnipotence

= persecutor


Idealised=

psychotic part


How does the presence, impact, interference or dominance of a

psychotic part manifest in every day social life?


responsibility limitations change dependence separation / loss ambivalence competition aggression desire guilt

non-psychotic part psychotic part

responsibility

limitations change

dependence separation / loss

ambivalence competition aggression

desire guilt

MIND – Social Brain

tasks of living tasks of social living

accepts rejects

motivational conflict


The motivational trajectories of the psychotic and non-psychotic parts of mind are diametrically opposed.

What is ordinarily viewed as ‘good’ from a non-psychotic perspective is fundamentally ‘bad’ or ‘dangerous’ from the perspective of the psychotic part.

This leads a person vulnerable to psychosis to be plagued by self-defeating doubt and ‘ethical dilemmas’.

ethical reversalsLiving with Psychosis

non-psychotic part

Good = Good

Bad = Bad

psychotic part

Good = Bad

Bad = Good

no ambivalence ! but either or, black or white

absolute ethics

ethical reversalsThe presence of the psychotic part of mind is identifiable in behaviour

and communication through the expression of characteristic ethical reversals:


http://www.qksrv.net/click-1127950-10281960

good = badlove = hateresponsibility = exploitation gratitude = accusationconcern = exposurehelp = humiliation / debt . . .


non-psychotic part

reality

psychotic part

omnipotence responsibility limitations change dependence separation / loss ambivalence competition aggression desire guilt

entitlement limitations denied change resented dependence denied separation / loss resented or denied and source of grievance either or / black and white aggression denied or projected onto other and perceived as persecution guilt categorically denied desire denied


From the perspective of the psychotic part, anxiety in the ego is experienced as persecutory anxiety.

The inherent narcissistic omnipotent response of the psychotic part is to rid the mind of experiences of persecutory anxiety or, if this proves unsuccessful, to retaliate.

Therefore, the psychotic part, from a quasi superego position, attacks the ego (or the object in borderline psychosis) for its ‘weakness’ of letting anxiety emerge and thus violating the reversed ‘ethical codes’ of the psychotic part.


engagement and interventionClinical and support interventions for people vulnerable to psychosis benefit from taking into consideration the relative presence and impact of a psychotic part of mind.

This involves the recognition and consideration of the presence of narcissistic omnipotent motivation interfering in ordinary tasks of living and relating – and of course in the professional or caring relationship.

Without this recognition interventions risk provoking the sensitivities of the psychotic part with consequent increased withdrawal and/or psychotic disturbance (negative therapeutic reaction).


engagement and intervention

It is critical to bear in mind that any intervention will be evaluated by conflicting motivational ethics – non-psychotic vs psychotic.

What may be considered ‘good’ from an ordinary perspective and support the non-psychotic part, will be seen to be ‘bad’ from the perspective of the psychotic part.

Maintaining engagement with both parts of the personality is both the challenge as well as the therapeutic driver of change / development / recovery


engagement and interventionCommunications with a patient / client / service user need to bear in mind, acknowledge, accept and address both the psychotic and non-psychotic parts of mind.

For example:

Acknowledge: ‘You said that you want to do this, but I think a part of you is concerned and does not want to do it’ Accept: ‘I think we need to accept that a part of you does not want to do this; yet another part does, and it is important that we keep both views in mind.’

Address: ‘I acknowledge and accept your concerns, but I don’t think that this can be done in an either-or, all-or-nothing way. Whether you do or don’t do this – there will be consequences, either way – it is difficult.’


engagement and intervention Engagement with the psychotic part requires diplomatic negotiating of narcissistic omnipotent demands or rejections of social relations.

Engagement, support and therapeutic work with people vulnerable to psychosis, is akin to being a peace negotiator mediating between the conflicting motivational ‘ethics’ of the non-psychotic and psychotic parts of mind.

The psychodynamic development model of psychosis is not primarily intended as a specific treatment model but as a guide, to better engagement and containment of psychotic interference when working with and supporting people affected by psychosis across the range of services and modalities.


engagement and intervention working within omnipotence / delusions awareness of and working within transference / repetition compulsion desire for change vs anxiety about / rejection of change reassurance can lead to negative reactions – ethical reversal maintain relational frame / therapeutic stance negative therapeutic reaction not cure but ongoing negotiation of motivational conflict focus on real life – psychosocial change / outcomes


Thank You

Paula Conway Consultant Clinical PsychologistDirector Grow2Growand Life-Work Training and Development

Andreas Ginkell Psychoanalytic PsychotherapistDirector Jobs in Mindand Life-Work Training and Development

www.life-work.co.uk [email protected]

07904616699


http://www.life-work.co.uk/

Documents

Living with Psychosis Paula Conway & Andreas Ginkell a psychodynamic development model of psychosis and its psychosocial application ISPS UK October 2012