In this post, Dave Keith reflects on how he came to understand psychosis as a symbolic expression, embedded in a person’s relationships and experiences. This offers an alternative, dynamic and life-affirming perspective on what is often considered the “destiny” of mental illness.
Dave: I want to talk about the story of my work with a young woman first who came to see me shortly after she experienced a psychotic episode. But first….
Psychosis: Destiny or Experience?
Before I begin the story I want to say a little about “psychosis”, a frequently used word in a variety of contexts, a poorly defined word that suggests disruption and loss of reason. Think for a minute, what is a psychosis? The conventional dictionary is brief, a “severe mental derangement”. The DSM is far more elaborate. In my unconventional reference, Keith’s Compendium of Flawed Explanations, psychosis is a psychosomatic or “psychosomatisystemic” state (body/mind/symbolic reality/relational context), in which a person’s powers of self-observation are compromised, they are over-whelmed by subjective experience. The social link (Davoine, History Beyond Trauma) is broken. It is non-voluntary, and conscious decision (cognitive behavioral training) has little to do with whether the state continues. In fact, the effort to impose reason on a psychotic person tends to push them away, deeper into their desperate and separate world. The psychotic person often experiences empathy as seduction, a manipulation.
The historical origin of the word “psychosis” fits my way of thinking experientially about psychosis. From the Greek, “psychosis” means “animation” or “principle of life.” The verb form has the implication “to give soul or life to.” This original definition is fascinating because it contrasts with the way the word is used in conventional psychiatry. A reactive psychosis is a reaction to overwhelming stress and desperation, something has happened. In my view all psychoses are ‘reactive’. If the stress is from harder-to-acknowledge symbolic experience it is more difficult to decode it. Further, ‘psychosis’ is not a destiny it is a profound transitional experience. The isolation that occurs with psychosis is what makes chronic impairment more likely.
As I have said before, all psychopathology is related to interpersonal experience until proven otherwise. In the case I will talk about, I attempted to explore and understand a young woman’s behavior in relation to her experience. I did not “examine” her, I interacted with her. Examination uses a particular kind of language based in applied science. A major step in my path to becoming a therapeutic psychiatrist was discovering and integrating a depathologized view of psychosis. “Depathologizing” means looking at mental disorders as experiences. This is done by contextualizing the person’s experience, paying attention to the effect of relationships, past and present, and paying attention at the symbolic level. The ability to do this depends upon the experience of the practitioner.
Another step in my development after discovering a depathologized view of psychosis was recalling a period in my life which I think of as my own psychosis (craziness). In young adulthood I had nonintrusive fantasies that I might be a messiah. That was a partial explanation for my early isolation and covert panic about my place in the world. However, I had the capacity to see around the fantasy. It affected my behavior, but it was hidden, I was never frightened by the fantasy. I never told anyone about it until I was in my 50’s.
Further the process of interaction means tracing how this result emerged, but I use “literary” language, not science/diagnostic language. Literary language is ambiguous, playful, seriously playful, parallel, ironic. Psychosis is a human experience, which is easy to turn into a pathological, dehumanizing experience. Psychosis is a vehicle not a destiny. Psychiatry looks upon the psychosis as a “disease” the result of a disruption in neurophysiology. They use a scientific lens to discern a diagnosis. They use the language of applied science to understand.
I look upon the psychosis as an experience. I am not romantic about psychosis. I do not underestimate the pain involved, the pain and panic of being a fractured isolated self, and what it often does. I have worked with many people over the years who make it through the psychosis. They decide not to continue, then come back a year later with anxiety symptoms and a disjointed feeling. They have a phobia of craziness. This phobia of craziness is a strong determinant of behavior in our culture. If they become confused they become wary they are headed back into psychosis.
I have reverence for the experience. I like to think my reverence is a potentially healing salve, applied to the family which of course includes the psychotic person.
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