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

2. 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

3. 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 Living with Psychosis

4.  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: Living with Psychosis

5. positive symptoms negative symptoms psychosocial dysfunction social withdrawal prodromal / remission acute episodes psychosocial disability Living with Psychosis

6. 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: Living with Psychosis

7. 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 Living with Psychosis

8. 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 Living with Psychosis

9. good parts / experiences states of mind bad parts / experiences states of mind mother – baby / infant unit absolute dependency on maternal care primary narcissistic omnipotence PARANOID / SCHIZOID POSITION annihilation / persecutory anxiety splitting / projective identification I Living with Psychosis

10. good parts / experiences states of mind bad parts / experiences states of mind mother – baby / infant unit absolute dependency on maternal care primary narcissistic omnipotence PARANOID / SCHIZOID POSITION annihilation / persecutory anxiety splitting / projective identification I she me beginning of me / not-me differentiation absolute dependence on maternal care subjective omnipotence birth of subjectivity Living with Psychosis

11. Subjective Triangulation I she me subject – object differentiation / Subjective Triangulation relative dependence on maternal care subjective – objective omnipotence Living with Psychosis

12. Subjective Triangulation forms the basis for Oedipal Triangulation I she her me myself other her self 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 Living with Psychosis

13. me my her his / her I other she her I other’s I his / her other Oedipal Triangulation forms the basis for Social Interaction Living with Psychosis

14. me my her his / her I other she DEPRESSIVE POSITION depressive anxiety repression desire / guilt = identified Oedipal Triangulation forms the basis for Social Interaction All relationships, social interactions are inescapably not just between two people! Every relationship is inherently affected by a third element – the other! Living with Psychosis

15. me my her his / her I other she DEPRESSIVE POSITION depressive anxiety repression desire / guilt = identified Oedipal Triangulation forms the basis for Social Interaction 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 Living with Psychosis

16. Oedipal Triangulation forms the basis for Social Interaction However, how does a person who operates from a paranoid schizoid position cope with social life? Living with Psychosis

17. Oedipal Triangulation forms the basis for Social Interaction I other her his / her me my she primary narcissistic omnipotence = persecutor PARANOID / SCHIZOID POSITION annihilation / persecutory anxiety splitting / projective identification Idealised = Living with Psychosis

18. me my her his / her I other she = identified Oedipal Triangulation forms the basis for Social Interaction Oscillation between functioning in the Depressive Position and operating in the Paranoid Schizoid Position does happen. DEPRESSIVE POSITION Living with Psychosis

19. Oedipal Triangulation forms the basis for Social Interaction I other her his / her me my she primary narcissistic omnipotence = persecutor Idealised = PARANOID SCHIZOID POSITION Living with Psychosis

20. me my her his / her I other she = identified Oedipal Triangulation forms the basis for Social Interaction DEPRESSIVE POSITION Living with Psychosis

21. Why do some people ‘interact’ with life more than others in the paranoid schizoid position? Living with Psychosis

22. 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. Living with Psychosis

23. ID primary narcissistic omnipotence MOTHER / OBJECT subjective omnipotence objective omnipotence secondary narcissistic omnipotence EGO SUPEREGO PSYCHOTIC PART Developmental Origins of the Psychodynamic Functional Structure of Mind Living with Psychosis

24. Oedipal Triangulation forms the basis for Social Interaction I other her his / her me my she primary narcissistic omnipotence = persecutor PARANOID / SCHIZOID POSITION Idealised = psychotic part Living with Psychosis

25. How does the presence, impact, interference or dominance of a psychotic part manifest in every day social life? Living with Psychosis

26.  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 Living with Psychosis

27. 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 reversals Living with Psychosis

28. non-psychotic part Good = Good Bad = Bad psychotic part Good = Bad Bad = Good no ambivalence ! but either or, black or white absolute ethics ethical reversals The presence of the psychotic part of mind is identifiable in behaviour and communication through the expression of characteristic ethical reversals: Living with Psychosis

29. good = bad love = hate responsibility = exploitation gratitude = accusation concern = exposure help = humiliation / debt... ethical reversals Living with Psychosis

30. 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 ethical reversals Living with Psychosis

31. 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. ethical reversals Living with Psychosis

32. engagement and intervention Clinical 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). Living with Psychosis

33. 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 Living with Psychosis

34. engagement and intervention Communications 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.’ Living with Psychosis

35. 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. Living with Psychosis

36. 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 Living with Psychosis

37. Thank You Paula Conway Consultant Clinical Psychologist Director Grow2Grow and Life-Work Training and Development Andreas Ginkell Psychoanalytic Psychotherapist Director Jobs in Mind and Life-Work Training and Development www.life-work.co.uk a.ginkell@jobsinmind.org 07904616699 Living with Psychosis