Living with Psychosis Paula Conway & Andreas Ginkell

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

2. Living with Psychosis 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.

3. Living with Psychosis 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

4. Living with Psychosis The psychodynamic development model of psychosis formulates this view and aims to: • 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

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

6. Living with Psychosis The psychodynamic development model proposes that: The psychosocial disability underlying psychosis is an inherent risk of the specifically human processes of development and maturation of the human ‘social brain’.

7. Living with Psychosis The evolved human maturational processes 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.

8. Living with Psychosis The psychodynamics of the evolved human maturational processes D.W.Winncott observed and described in psychodynamic terms the experiential processes of this evolved human maturation. mother – baby unit omnipotence phase of total helplessness - absolute dependence on maternal care – there is no such thing as a ‘baby’ mother has objective omnipotence – baby has ‘subjective’ illusion of omnipotence baby’s primary narcissistic omnipotence

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

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

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

12. Living with Psychosis • Subjective Triangulation forms the basis for Oedipal Triangulation subject Is the other in her mind me? - other I I am another ! I am competing with others for this place in her mind me myself herself she I she her she is also an I object self She has also a mind like mine subject

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

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

15. Living with Psychosis • 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 his / her DEPRESSIVE POSITION depressive anxiety repression desire / guilt I other = identified memy her she

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

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

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

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

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

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

22. Living with Psychosis 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. mother – baby unit omnipotence

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

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

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

26. Living with Psychosis tasks of living tasks of social living MIND – Social Brain psychotic part non-psychotic part rejects accepts responsibility limitations change dependence • separation / loss ambivalence • competition • aggression desire guilt responsibility  limitations change dependence separation / loss ambivalence competition aggression  desire guilt motivational conflict

27. Living with Psychosis ethical reversals 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’.

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

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

30. Living with Psychosis ethical reversals psychotic part non-psychotic part omnipotence reality 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 responsibility limitations change dependence  separation / loss ambivalence competition  aggression desire guilt

31. Living with Psychosis ethical reversals 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.

32. Living with Psychosis 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).

33. Living with Psychosis 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

34. Living with Psychosis 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.’

35. Living with Psychosis 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.

36. Living with Psychosis 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

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