Wednesday, 9 December 2015

Psychoanalysis and Schizophrenia?

I've just finished reading Christopher Bollas' newest book When the Sun Bursts, about his work providing psychoanalysis to people going through psychosis. I realised I feel very mixed about it, and I suspect this tells me about my ambivalence about psychoanalysis more generally.

Psychoanalysis and schizophrenia fell out with one another in the 1980s, when the idea that the latter was a brain based disorder began to usurp the notion (mainstream in the 1950s, 60s and 70s US) that it was a psychological reaction originating in family dynamics. Many things contributed to the therapeutic divorce. The overall background was the rise of biological psychiatry and the renewed interest in using the DSM as a systematic tool for empirical research, but several historical events also conspired to paint psychoanalysis in a particularly unfavourable light. One major blow was the Chestnut Lodge Follow Up Study, conducted by Thomas McGlashan, a psychiatrist with sympathies to psychoanalysis who became curious about how effective it was. He examined the long term outcomes of patients at Chestnut Lodge (pretty much the world center of psychoanalytic treatment for schizophrenia) and concluded they were not being helped by their treatment. Another was the Osheroff Case, in which a physician with severe depression was treated psychodynamically and tried to sue Chestnut Lodge for not deploying the most effective treatment.

The Osheroff case did not actually concern an individual with a diagnosis of schizophrenia, but the principle at stake (whether psychoanalysis was an effective treatment for a severe and enduring psychological difficulty) was highly relevant to that diagnosis. Furthermore the case concerned treatment at, again, Chestnut Lodge. Many histories of psychiatry cite these events as key factors in the decline of psychoanalysis as a treatment for schizophrenia. One such (Edward Dolnick's Madness on The Couch) reads as a stern polemic, taking psychoanalysis to task for victim blaming. Another, Jeff Lieberman's Shrinks (review by me here), is a good example of how contemptuous many psychiatrists are about Freudian therapies and ideas.

So in one sense, Bollas' book looks like an anachronism. Few now expect psychoanalysis to ameliorate psychosis anymore, and Bollas is aware of the of how widespread is this view. He skirts the issue:

But goes on to makes a claim (a few pages later) which is quite definitie in nature and would require just the sort of outcome study that Bollas has recently repudiated:

This sort of sophism is irritating; does Bollas want to claim his approach is effective, or does he not? It's tempting to dismiss him altogether at this point, but does reading someone like Bollas have anything to teach us? I think it might.

It is not totally outlandish to suggest that R.D. Laing wrote one of the 20th century's best books about psychosis. The Divided Self is an unparalleled masterpiece of phenomenology (read it if you haven't already). Yet at the same time, there is also something approaching consensus (from what I have read) that his major therapeutic innovation, the Philadelphia Association, was something of a failure. Sure you can read Mary Barnes and Joe Berke's favourable account of a "Journey Through Madness", but when it comes to a more overarching view of the project (as found in Daniel Burston's very respectful biography of Laing), it doesn't look like the majority of people were helped any more than they would have been without the Scottish guru.

What Laing offered the study of psychosis then was not a viable alternative therapeutics (ultimately it's not clear that his notion of psychosis, as a revelatory journey one must past through, offered the sort of safety and serenity that might be optimal in a residential setting) but a powerful vision of how we can approach highly disorganized and disoriented people as people, with a degree of empathy and openness to listening to their experiences. Whatever packaged and marketed therapies are regarded as appropriately evidenced and offered in healthcare services, this sort of humane engagement is not only highly desirable, it is unavoidable. Whether you are discussing a person's medication, their experiences or their occupational aspirations, you need some way of taking them seriously and understanding what it might be like to live in their head. Laing's description of ontological insecurity, followed by the development and ultimate collapse of a protective "false self" system allowed clinicians to at least imagine what might lead to behavior which is so confusing as to be routinely described as "mad".

It is this kind of imaginative material that Bollas offers, and it is what makes his new book worthwhile for clinicians, even if they don't follow him all (or even most of) the way. Bollas and many other analysts (and not just analysts) may eschew the value of evidence in psychotherapy, but that doesn't invalidate everything they have to say. Whatever you think of the benefits of psychoanalysis as a therapy, it still has potential as a mode of observation and phenomenological hypothesis forming. None other than Paul Meehl once wrote a very effective argument to the effect that the un-testability of many psychoanalytic assertions does not itself render them untrue or worthless. If you take empathetic and highly attentive individuals (psychoanalytic clinicians) and put them in a situation in which they observe people's verbal behaviour over long periods of time, it seems highly implausible that they wouldn't derive any very insightful and useful ideas about how minds work.

Bollas' book has many such ideas. He suggests that the symptom of hearing voices is the result of "despositing" unwanted parts of the self in the environment such that they start to talk back to you, representing aspects of your past in ways that demand to be listened to. He describes the experience of the separation of the "I" from the "me", such that people with psychosis may split their self and behave in remarkable ways once they have done so . He suggests that people in the grips of a psychosis may be so frightened by their thoughts that they take an (often bizarre seeming) action to prevent having them. This sort of deep meditation gives rise to some remarkably empathetic moments:

Such intuitive accounts may be "wrong" (in the sense that they don't really get at what individuals experience) but they strike me as preferable to a defensive dismissal of people's "crazy" experiences. Many mental health services for psychosis currently isolate patients and ignore their experiences, alienating rather than engaging them. If social isolation is an exacerbating factor in the deterioration of people's mental health, we need to find ways of spending time with such individuals, even at their most disorganized and frightening. At least Bollas (and he is in a long line of psychoanalytic clinicians on this score) is trying his damnedest to connect.

Some of his ideas I found intuitive and quite striking, others (the obscure theory of "Metasexuality") I found maddeningly arcane. As Meehl (and many others) have pointed out, there may be no decent way to adjudicate between them, but unless you subscribe to a sort of rigid Vienna-Circle logical positivism in which statements about the self can only ever be empty "metaphysics", they don't seem entirely worthless. Are we only interested in ideas that are testable scientifically? Surely not; many highly speculative and unverifiable ideas (the dialectic movement of history) are valuable, so long as you have a clear distinction in your mind between them and some notion of "truth". We value novelists and poets who can illuminate their inner worlds through their vivid writing, why not try and find some similar worth in the imagination of psychoanalysts?

If you are still queasy about such unscientific shenanigans, it's worth remembering that a phenomenological account is not inconsistent with an informed empirical one. I'll end with a quote from one of Paul Meehl's best papers:

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