Possibilities of psychoanalytic therapy in work with psychotic subjects.

Introduction.

The article you see before you is inspired by my work with psychiatrists at the City Clinical Psychiatric Hospital in Tashkent. In the process of working with psychotic patients at this hospital, a number of questions have been formed about the place of psychoanalytic therapy in working with people suffering from mental illness in Uzbekistan. Today, psychiatry is increasingly trying to take a humanistic approach and incorporate psychotherapy in the treatment of psychiatric patients. However, psychiatry suffers from a lack of understanding of the task and meaning of long-term psychotherapy as a method of treating psychotic conditions. Psychoanalytic psychotherapy does not promise quick results and cannot replace pharmacotherapy for a patient who, within psychiatry, is viewed from the perspective of a biochemical disturbance. From the side of purely somatic causes, pharmacological treatment, although it may be long-lasting, ends up leaving the psychological causes of the disease unaffected, thus increasing the risk of relapse of the disease.
Psychoanalysis as a science has in a sense always been in the border zone between psychiatry and psychology. After all, all psychoanalytic theory originates from practice in psychiatric clinics in Europe. In particular, Sigmund Freud investigated hysterical conversion symptoms in the late nineteenth century at the Salpêtrière Clinic. And Jacques Lacan was a psychiatrist by training and a pupil of G. Clérambault, on whose work modern psychiatry is based. Thus, throughout the entire existence of psychoanalysis, its clinic cannot be imagined and comprehended in isolation from psychiatric practice.
Mental disorder has a strong impact on the quality of life of the subject, e.g. strange behavior, its unpredictable nature can alienate not only friends and colleagues, but also the closest family members. It can provoke de facto social isolation, anhedonia, impaired self-care, inability to take medication, and as a consequence leads to worsening of the symptoms of the illness. The general stigmatization of mental illness creates a barrier between society and the person suffering from mental illness.
The practice of working with patients during and after treatment in a psychiatric clinic reveals problems in the psychoanalyst's work with people suffering from mental illness precisely because of their personality traits and the traits that have developed as a result of the illness. This is especially true with regard to the creation and maintenance of a therapeutic setting and the possibility of working with transference feelings, which in turn raises the question of the choice of specific therapeutic methods of work.
This article will address the issue of therapy for psychotic patients in a holistic manner, drawing on psychoanalytic understanding and typology of psychosis, as well as theoretical understanding of the mechanisms of psychosis. It will also explore methods that, despite their peculiarities and limitations in working with psychotic subjects, may be effective and applicable in therapy.

Psychosis and neurosis in Freudian theory.

Based on the psychiatric nosology of mental disorders, as well as on clinical experience, in 1924 Freud created a classification of mental illnesses, attempting to conceptualize and group mental illnesses in the second topicality of the Self, Super-Self, and Ono. In Neurosis and Psychosis, he defines three types of psychotic states with fundamental differences: "Transference neurosis corresponds to the conflict between the Self and the It, narcissistic neurosis corresponds to the conflict between the Self and the Super-Self, psychosis corresponds to the conflict between the Self and the external world" [17].
This classification, although it is the basis for all subsequent ones and indicates the fundamental differences between neurotic and psychotic states, is still outdated. The modern theory of psychoanalysis divides neuroses (hysteria, phobias, obsessive-compulsive) and psychoses (manic-depressive state, paranoia, schizophrenia). Let us further consider the main features of each condition, and the differences between neurosis and psychosis.

Neuroses.

The neurotic mode of functioning refers more to the neurotic personality structure, and is not a disease in the broad sense of the word, yet we cannot dismiss existing acute neurotic states that may be perceived as psychotic. Indeed, quite often neurotic subjects become patients of psychiatric clinics, due to the occurrence of acute states resembling psychotic ones. In the modern classification of diseases (ICD-10) there is no diagnosis of neurosis, instead there is a diagnostic category: Neurotic, stress-related and somatoform disorders.
This group of mental disorders includes hysteria neuroses, phobias, and obsessive-compulsive neuroses. Patients with these conditions are characterized by a high capacity for creating and being in transference feelings toward the physician or psychoanalyst. This is why Freud called these conditions transference neurosis as early as 1924. This means that all of the subject's inner conflicts are transferred to the psychoanalyst in a therapeutic setting, which allows the transference to be interpreted and processed in a symbolic register. Patients with neuroses are characterized by high criticism of their condition, which creates favorable conditions for complete remission of the disease. Next, let us consider the peculiarities of each type of neurosis:
Hysteria neurosis is a condition in which hysterical symptoms such as paralysis, seizures, blindness or deafness reach psychotic levels and may be accompanied by hallucinations or delusions. The condition is characterized by dramatic emotional manifestations and somatic symptoms that have no organic basis. One of the most famous cases, described by Z. Freud and J. Breuer in Studies in Hysteria, concerns Anna O., a patient with multiple somatic and psychic symptoms. Her condition was considered as an example of hysteria with elements of psychosis [16]. Currently, hysteria is more often defined as a dissociative (conversion) disorder.
Obsessive-compulsive neurosis is a psychoneurosis characterized by obsessive thoughts and compulsive behavior of a person. Obsessive thoughts are felt as repetitive, monotonous, imposed from outside and beyond the person's will, and their content is strange, inappropriate, obscene. Compulsive behavior is characterized by the desire to perform meaningless actions, which, being motor equivalents of obsessive thoughts, become ritualistic and stereotyped. Various symptoms such as compulsive hand washing, various household rituals and accompanied by increased mentalization of these processes are found in the clinic.
Psychoanalytic understanding of obsessive-compulsive neurosis focuses on the role of unconscious conflicts and defense mechanisms. Freud believed that obsessive-compulsive neurosis is associated with the anal stage of development, where conflicts arise around issues of control, cleanliness, and order. And obsessive thoughts and compulsive acts serve as a defense against the anxiety caused by these conflicts [15].
The phobia neurosis according to Freud is only a phase in the development of fear hysteria, which manifests itself in anxiety attacks. Over time, avoidance of certain situations and objects may take center stage in a person's life. Very often phobias are associated with childhood experiences and fears. In addition, defense processes such as projection and displacement can be identified. Thus, a phobia serves as a disguise for an unconscious psychological threat [14]. In the clinic we meet such manifestations of phobic states as panic attacks, agoraphobia, childhood fears (fear of strangers or the dark).

Psychosis.

As we will see below, each of the psychotic states has its own unique clinical picture, but psychoanalytic theory agrees in defining psychosis as a mental disorder with which is associated a disturbed function of reality testing and the distinction between self and object. The use of primitive defenses and the failure to use higher ones is also a hallmark of the psychotic state. Although there is not always the presence of delusions and hallucinations in the clinic, psychotic subjects have clearly bizarre forms of behavior, ways of thinking and feeling [11].
After developing the second topicality, Freud believed that any psychotic state is a gap between the Ego and reality, which leads the subject to construct a new reality in accordance with the needs of the Ono. The new reality appears in the form of delusions and hallucinations, where delusions act as a defense against traumatic events in reality, and as a way of not encountering this reality [19].
Manic-depressive state (BAD according to ICD-10). It is characterized by a deep sense of hopelessness and insignificance. The subject may experience delusions of guilt and self-deprecation. Freud relates this state to the loss of the object of love and the inability to engage in an adequate mourning process, whereby the object is introjected and the subject remains protected from its loss.
In his work Grief and Melancholy (1917), Freud views melancholia (depression) as a reaction to loss. Unlike the normal grieving process, in which the subject is aware of the loss and gradually copes with it, in melancholia the loss is unconscious. The subject does not realize what exactly he or she has lost and instead transfers aggressive feelings to the self, which leads to self-recrimination and lowered self-esteem [21].
In manic-depressive states, the depressive phase is characterized by deep sadness, loss of interest in life, self-care, and suicidal thoughts. Mania is seen by Freud as a defense mechanism against depression. In the manic state, denial of loss and suppression of guilt occur, resulting in temporary euphoria and hyperactivity [21]. In the manic phase, the patient experiences elevated mood, hyperactivity and grandiose ideas. A low degree of criticism of the illness is observed.
Paranoia is characterized by a predominance of delusions, often involving persecution. The subject may have an illusory feeling that he or she is being watched or wants to harm him or her. This condition is often associated with the mechanism of projection, where the subject's internal conflicts are transferred to external objects. The subject places his aggressive, destructive perceptions into the external object, thus successfully dissociating himself from the fantasy of destroying the object. As a result of this projection, the object itself is endowed with the intention to destroy the subject. The paranoiac patient often chooses the paternal figure as the haunting figure [20].
Freud also noted that paranoid psychosis utilizes the denial mechanism, where the subject denies unacceptable reality, and the isolation mechanism, where the parts of reality that cause anxiety are cut off.
Schizophrenia. In the schizophrenic state, according to Freud's idea, there is a detachment of the libido from external objects and its return to the self. This leads to a breakdown of connection with reality and the formation of internal fantasies. Freud saw schizophrenia as the result of a regression to earlier stages of psychosexual development. The regression reaches back to an early stage of libido development, autoeroticism, without stopping at the stage of narcissism [18]. In this way, the patient can return to the early stages and the simplest modes of interaction. Thus schizophrenic psychosis is associated with the disintegration not only of the psychic self and psychic reality, but also with the disintegration of body image. The perception of the body for the schizophrenic patient is fragmented because of the regressive return to the autorotic stage where the child does not yet have a coherent body image and the body is perceived as a set of fragments. This is why Freud concludes that therapy for schizophrenia has a less favorable prognosis than working with paranoia.
In schizophrenia, in addition to hallucination, there is overinvestment in verbal representations. In the clinic we can notice such speech disorders as syntactic disorganization, use of neologisms and nonsense, distortion of meanings and inability to metaphorically perceive the meaning of words and phrases, since all words and phrases are taken literally [7].

The main theories of the origin of psychosis of Freud's contemporaries and post-Freudians.

After Freud, many psychoanalysts conceptualized psychotic states, let us consider the theories of the object relations school, as well as the French school of psychoanalysis and their theories that allow us to conceptualize the clinic of psychosis.

Good Inner Object and Reality Testing (M. Klein).

Melanie Klein viewed the state of psychosis as an escape to a good internal object, while neurosis is an escape to a good external object [5]. In psychosis, the patient may seek solace and safety in the illusion of merging with a good object to escape the destructive anxieties associated with bad objects. Klein describes psychotic regression as a movement back to more primitive stages of mental development, where internal objects become more significant than external reality.
In the article "Grief and its relation to manic-depressive states" (1939), M. Klein takes Freud's notion of reality testing as a basis and outlines her concept of the depressive position. She writes that depression reveals a disruption of reality testing, which refers us back to the infant's early experience of the depressive stance. It is this disorder that is the obstacle to recovery from depression, for reality testing allows for the separation of reality and fantasy, and coming to terms with the frustrating nature of reality where the object is lost. This mechanism is characteristic of pathological grieving (melancholia). Whereas the mania stage is due to a temporary sense of possession of a favorite object and a sense of euphoria from holding that object [6].

Studies of psychosis (W. Bion).

У. Bion, in his works on psychoses, noted the distinguishing features of psychotic patients from patients with neurotic organization. In particular, he points out that neurotic patients are characterized by the ability to integrative assessment of the surrounding reality. This is due to the presence of the ability to adequately perceive information, the preservation of the sensory sphere, and a properly functioning thinking apparatus. In his opinion, subjects with a dominant psychotic part of the personality, and in particular schizophrenic patients, are unable to be tolerant of mental pain or frustration because of the inability to correctly evaluate and coexist with the frustrating reality. Hallucinations are thus a way of creating a reality where there is no room for frustration and the lost object is always there [3].
Using the concept of projective identification developed by M. Klein, Bion talks about pathological projective identification, which is used by some psychotic patients, when the subject's Ego is split into a large number of disparate parts, which are projected onto the object in a chaotic order [1]. This allows us to understand the reason for the unstable transference that is established with the psychotic patient in the therapeutic setting.

Foreclosure of the Father's name (J. Lacan).

The concept of the forclusion of the father's name was introduced by Jacques Lacan. It is a key concept in Lacanian psychoanalytic theory, describing the mechanism of psychotic rupture due to the absence of a symbolic father's name. Lacan considered forclusion as a mechanism that distinguishes psychosis from neurosis, pointing out that in psychosis the symbolic meaning of the paternal law is discarded from the symbolic order, whereas in neurotic patients there is a mechanism of displacement [7].
In his works, Lacan formulates the Name of the Father as the symbolic place of the paternal law that structures the subject's psychic reality. And in the seminar "The Formation of the Unconscious" Lacan points out that the Father's Name is the signifier that gives the law its support [8]. The foreclosure of the father's name means that the symbolic meaning of the father figure is not recognized or incorporated into the symbolic order, leading to hallucinations and delusions as attempts to fill this gaping absence [7].

The mirror stage and its relation to psychosis (J. Lacan).

During the mirror stage (6-18 months of life), the infant, looking in the mirror, begins to recognize his reflection and realize it as a complete image of his own body, separated from the Other. Through identification with this image, the infant first begins to perceive himself as a whole subject, although this awareness is still based on the external, mirror image rather than on an internal sense of wholeness. This event will mark the beginning of the formation of the function of the self [10].
As already mentioned, in Lacanian theory, psychoses are often associated with the forclusion (discarding) of the symbolic name of the father, which prevents the proper integration of the subject into the symbolic order. The mirror stage, being the first stage of entry into the symbolic order, can be disrupted or distorted by this discarding. For example, instead of a coherent self, a fragmented perception of self and others emerges, and the subject may have difficulty distinguishing between the real and the imaginary, leading to hallucinations and delusions.
Disturbances in the mirror stage can lead to psychotic states characterized by fragmentation of identity and an inability to integrate symbolic elements of the psyche. Understanding this stage is key to understanding the mechanisms of schizophrenia.

Fear of disintegration (D.W. Winnicott)

In his article "Fear of Decay," Winnicott takes decay as the basis for his discussion, which is seen in the sense of the failure of protective organization. He describes the infant's psychic death as a primary agony that can occur as a result of excessive, early deprivation that the child was unable to understand or avoid. However, it is the stage of primary agony that facilitates the organization of the young subject's psychic defenses.
The supportive environment guides the child from the stage of dependence, through relative dependence to complete independence, but in cases of schizophrenia this process can proceed regressively and bring the subject back to reliving the early experience of primary agony. And then mental illness is a protective organization in relation to this primary agony, when the environment was excruciatingly excessive [4].

Psychoanalytic methods of working with psychotic subjects.

Transference in working with the psychotic subject.

Patients suffering from psychotic disorders (severe depression or schizophrenia) appear less able to adequately reproduce childhood conflicts and psychic traumas. They find it much more difficult to form a transference and enter into communication with the therapist by talking to themselves, which is why Freud called such psychotic disorders narcissistic [18]. Within the framework of classical psychoanalysis, in Freud's time, it was believed that psychoses were not amenable to psychoanalytic therapy precisely because of the narcissistic nature of these disorders, as there is a situation that prevents transference from occurring.
As has been shown, the concepts of neurosis and psychoneurosis in Freud's time were united by the general concept of transference neurosis. This association is due to the fact that patients with hysteria neurosis, obsessive compulsive neurosis, and phobias relatively easily form a transference to the psychotherapist or physician, treating him or her as a significant childhood figure, and also relatively easily reproduce in psychoanalytic therapy their infantile traumatic experiences that took place in early childhood (13). Modern psychoanalysis shows that psychotic patients create a specific transference and are thus amenable to treatment. In the case of psychosis, however, the formation of the transference is accompanied by various kinds of distortions that require special attention and treatment on the part of the analyst. The difficulty of analytic work lies in detecting, interpreting, and resolving the psychotic transference.
As mentioned above, the psychotic subject constructs his own unique reality, discarding the reality with which he does not wish to come into contact. Thus he himself, his desires, thoughts, affects, and actions are disconnected from reality. This can be strongly reflected in the transference, when the therapist is caught up in the delusional reality of the patient.
In psychotic transference there is always the question of paranoia, intrusion, and omniscience of the analyst and the possibility of distancing oneself from it. "In the dynamics of transference, the technique of attachment is constant. In working with the psychotic subject, symbolization is possible, but not interpretation. It is important for the psychoanalyst in transference to hold on to the position of the one who knows, who understands, that is, the position of the big Other. What is important is withdrawal." [12].
Thus we can formulate the main ideas related to the work of the transference relationship with psychotic patients. First of all we can note the instability and fragmentation of the transference. The psychotic patient projects many fragments of his fragmented self onto the therapist, and the therapist must be prepared for unexpected manifestations of the transference and its transformations. The nature of the detachment of the patient's delusions from reality makes it difficult to find a foothold for analysis and interpretation. Thus the rejection of omniscience, the search for a bearing in the transference, and attempts at interpretation become the therapist's basic position in working with the transference of the psychotic patient.

Symbolization and the role of signification in working with psychosis.

As mentioned above with psychotic patients the function of interpretation fails, while symbolization can have a good therapeutic effect. The process of symbolization allows us to restore the symbolic order, which includes laws, language, culture and all those elements that give meaning to our reality and is structured by signifiers [7]. The signifiers structure our perception of the world and identity through language and social laws. In the absence of a stable symbolic order, the psychotic subject finds it difficult to interpret reality, which can lead to delusions and hallucinations.
Symbolization involves the subject's ability to use language and symbols to denote their thoughts, emotions, and experiences. This allows experiences to be integrated into consciousness and given meaning [7]. In the therapy of psychosis, an important task is to restore or establish symbolic order. This may involve helping the patient to find new signifiers to structure their experience. It is important that this process be sensitive and respectful, as delusions and hallucinations often have deep personal meaning for the patient. It is just as important to remain in the position of secretary for the psychotic, as if recording what is happening and waiting for the opportune moment to return this recorded in symbolic form. It is important for the psychoanalyst to remain in the position of not knowing, without trying on the position of the total Other, to give up his or her knowledge in favor of exploring the psychotic subject (9).
In therapy with psychotic patients, the psychoanalyst may work to establish symbolic connections that will help the patient structure his or her experiences and thoughts using various types of creativity. This may include not only working with language, such as naming symptoms and helping the patient find new ways of expressing his or her inner world, but may also include working with visual images, the creative inventions of the psychotic patient. Examples of such work might include working with painting, appliqué, or modeling.

Containerization techniques when working with psychotic subjects.

The container-container concept is a dynamic interaction between the analyst (container) and the patient (containerized) where the analyst receives and processes the patient's emotional experience.
Container: the function of the therapist who receives, holds, and processes the patient's emotional experience.
Containerized: the patient's emotional and mental experiences that he or she cannot process on his or her own and needs the analyst's help to make sense of them.
The concept of containerization was introduced and developed by Wilfred Bion. Bion introduced the concepts of alpha function and beta elements. Alpha function refers to the ability to transform raw, unstructured emotional experiences (beta elements) into meaningful and symbolically processed forms (alpha elements), which allows these experiences to be integrated into a mental structure [2].
Containment is a central aspect of the therapeutic process where the analyst provides a safe space for the patient by accepting their emotional experiences and helping them to make sense of them [1]. During the therapeutic process, the patient expresses their intense, chaotic and disturbing emotions and the therapist acts as a container that takes these feelings, processes them and returns them to the patient in a more acceptable and meaningful form. This process helps the patient feel that their emotions and thoughts are accepted, understood and structured, which helps to reduce anxiety and improve psychological well-being.
Psychotic patients often experience intense and disorganized emotions that they cannot integrate into their mental structure. The therapist accepts these emotions without rejecting them and holds them in the therapeutic space. When the patient shares his delusions or hallucinations, the psychotherapist takes these experiences seriously without rejecting them. He or she helps the patient understand what emotional states or internal conflicts may underlie these symptoms. For example, the therapist may help the patient see the connection between his fears and what is expressed in delusions. This process requires the therapist to be able to withstand the emotional burden and remain in a state of empathy and understanding.

Conclusion.

Low social status, social isolation and the inability to be full members of society, makes patients with mental illnesses unattractive for long-term therapy by both psychiatrists and psychoanalysts. Therapy requires the interest of the analyst as a researcher, for working with the psychotic subject is an exciting and to some extent dangerous endeavor. However, psychoanalytic theory and practice provide an opportunity to conceptualize and analyze the psychotic state, and to help the patient fit into society and become a full member of it.
It is important to note that psychoanalytic therapy cannot replace pharmacotherapy in the case of an active stage of psychosis, nor can it be considered an alternative to such treatment. However, long-term and in-depth therapeutic work is necessary to increase the chance of partial or complete remission of mental illness and it is psychoanalytic therapy that has its own structured understanding of psychosis and the methods necessary to work with it, and can be applied outside the classical therapeutic setting and in the context of psychiatric treatment.
The theory of psychoanalysis, from Freud's theory to the theories of modern psychoanalysts, has been conceptualizing the mechanisms of psychosis for over a century. Freud views psychoses as a rejection of unbearable reality, and Melanie Klein in turn adds that the subject does not simply reject reality, but flees from it to a good object within himself, which is what gives mental disorders their narcissistic character. Winnicott noted the regressive course of the relationship with the environment and the return to earlier modes of functioning. Lacan, in his theory of psychosis, identified the key role of the Father's Name function, the absence of which is crucial to the psychosis clinic.
Therapeutic work with psychotic patients poses a number of challenges for the therapist. Working with transference feelings, which is difficult but still possible within the interaction with the psychotic patient and involves a certain stance of the analyst, which is expressed in withdrawal, denial of knowledge and distancing. The rejection of knowledge becomes an important aspect of the therapist's work in transference. The psychotic subject experiences the constant presence of reality; he or she is hardly separated from it. This creates a potentially paranoid situation in the transference; the therapist is threatened with becoming an omniscient stalker.
Working with the transference with the psychotic subject, which is of a fragmented, disconnected nature, reveals the need for a certain therapist stance toward the transference, such as the need to abandon the search for reliance and interpretations.
The inapplicability of interpretation in working with a psychotic subject can also be a challenge for the therapist who is used to working with subjects outside the psychotic state. However, abandoning interpretation and turning to symbolization creates opportunities to use different modes of symbolic expression, such as therapeutic mediation through art. Symbolization as a tool of work is more applicable in work with psychosis, as an opportunity to restore the symbolic function as such.
One of the most important techniques for working with psychotic patients is containerization, where the analyst acts as a container of the patient's chaotic experiences, and by giving them symbolic form, returns them to the patient in the form of bearable experiences. The containerization technique is particularly effective in working with body image disorders, where the therapist and the therapeutic space are able to hold together the disparate parts of the psychotic's body and psyche.
The treatment of psychotic patients is a challenge to the contemporary practice of psychoanalysis. It is a process that requires not only a great deal of experience in working with patients and experience in long-term personal therapy, but also a high degree of involvement and courage on the part of the analyst in the process of exploring the psychotic patient.