1. FINDING A ‘COMMON LANGUAGE’: A YEAR’S WORK USING A PSYCHOANALYTIC APPROACH WITH AN INDIVIDUAL EXPERIENCING PSYCHOSIS Beatriz Sanchez Head of Psychology Huntercombe Hospital Roehampton ISPS UK Residential Conference CHANGING REALITIES: NEW DEVELOPMENTS IN PSYCHOLOGICAL APPROACHES TO PSYCHOSIS Birmingham UK 1

2. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 1.Introduction 2.Psychosis and psychoanalysis 2.1Freud and psychosis 2.2The post-Freudians and psychosis 2.3The psychotic structure The Oedipus complex The mirror stage Entering the symbolic realm 2.4Phases of psychosis 2.5How to work with psychosis 3.A case study 3.1Making it safe 3.2Beginning the work: anger, violence and guilt 3.3Sex and identity 3.4Working through an ending 4.Conclusion 2

3. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 1.Introduction The Huntercombe Hospital Roehampton forms part of the Huntercombe Group, a specialist healthcare provider, with hospitals and centres located throughout England and Scotland. The Huntercombe Hospital Roehampton, is a 39 bedded in-patient hospital, a locked service for acute and rehabilitation needs of patients with high dependency and challenging behaviour. We focus on treating complex mental health/neuropsychiatric conditions and acquired brain injury in adult patients. We provide care to consenting patients and those detained under both civil and forensic parts of the Mental Health Act. 3

4. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 2.Psychosis and psychoanalysis 2.1 Freud and psychosis Hallucinations and delusions as secondary symptoms, a response to the disorder. Paranoia: a fixation to narcissism. 4

5. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 2.Psychosis and psychoanalysis 2.2 The post-Freudians and psychosis – M. Klein: the use of psychological primitive defence mechanisms to defend from extreme states of anxiety, aggression and fear. – W. R. Bion: a conflict between the psychotic and the non-psychotic parts of the personality. – R. Lucas: denial and rationalisation. – N. McWilliams (1994): ‘...the primary conflict is existential¸ life versus death, existence versus obliteration, safety versus terror’ (McWilliams, 1994, p. 59). – A. Black (2008): ‘the disturbance in meaning and language (...) and the disintegration and fragmentation of the awareness of self and identity’ 5

6. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 2. Psychosis and psychoanalysis 2.3The psychotic structure A failure of the paternal metaphor. A failure in the formation of the ego. The Oedipus complex The paternal metaphor links the father and castration. (a) the cognitive realisation of the presence and absences of the mother by the child (b) the child links these with something beyond her, usually identified with the father. The mirror stage There is impairment in the ego-formation, which results in a failure of the infant developing a secure sense of himself and differentiating himself from others (Jackson, 2001). Entering the symbolic realm ‘A mediator is needed from the outside to move the infant from this space where there is only the subject and the mirror image. The adult, usually the mother confirms the image binding it to the child through speaking and through her gaze. This experience will determinate the child’s experience to inhabit his body image. 6

7. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 2.Psychosis and psychoanalysis 2.4 Phases of psychosis An enigmatic experience The pre-psychotic world has collapsed. Re-establishing meaning There is a desperate tendency to construct delusional formations in an attempt to rebuild a semblance of a meaningful world. Reconstruction The individual then begins to be able to doubt the certainty of the delusional structure built up in the previous stage. 7

8. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 2.Psychosis and psychoanalysis 2.5 Working with Psychosis - To contain - To create meaning - To accompany the dread A secretarial role ‘The work of helping the psychotic subject create a history, through naming, dating, isolating and detailing, emphasized by Harry Stack Sullivan, is in some senses a secretarial duty...’ (Leader, 2011, p. 305) 8

9. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 3.A case study – Jack 9

10. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 3.A case study – Jack 3.1Making it safe 3.2Beginning the work: anger, violence and guilt 3.3Sex and identity 3.4 Working through an ending 10

11. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 3.A case study – Jack 3.1Making it safe (months one to three) 11

12. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 3.A case study – Jack 3.2Beginning the work: anger, violence and guilt (months four to eight) 12

13. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 3.A case study – Jack 3.3Sex and identity (month nine) 13

14. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 3.A case study – Jack 3.4 Working through an ending: An executive summary (months 10 and 11) 14

15. Last phase: working through our ending, an executive summary (months 11 and 12) 15 Jack is a young man in his thirties. He is pleasant and intelligent; he is also a gentleman and good in nature. Jack experiences unusual experiences and he is often in severe emotional pain. He is often in dialogue with his friends. They, others cannot hear. They are sometimes comforting but they can also be nasty and create a conflict for Jack. He is trying not to mumble to himself because he is moving out of this hospital into a mixed ward soon and wants to do well there. He has found our sessions helpful because he can talk openly about his thoughts, even if sometimes we cannot find a common ground. Other times we have found common ground and he has learnt things about himself. Jack has fantasies and talks an unique dialect. Sex is important to Jack and we have spoken about it often and how to manage his sexual needs and desires. He has a troubled past. There is especially one incident within his family. We have talked about it and how to make himself and others safe so that another incident does not occur. Jack has thought carefully about his own sexual identity. Plan of action To continue striving to find common ground with others, To seek advice regarding how to manage sexual needs and desires, To continue to work on being assertive with others.

16. Finding a ‘common language’: A year’s work using a psychoanalytic approach with an individual experiencing psychosis 4.Conclusion - A double problem for Jack: psychosis and a trauma. - From a dialogue with himself to a dialogue with an other. - A secretarial role: containing, making meaning and accompany the dread. 16