From Allen, J.G. & Collins, D.T. (1996) Contemporary Treatment of Psychosis: Healing Relationships in the Decade of the Brain, New Jersey, Jason Aronson, ps.1-25

Chapter 1.

Orphans of the 'Real: I. Some Modern and Postmodern Perspectives on the Neurobiological and Psychosocial Dimensions of Psychosis and Other Primitive Mental Disorders

James S. Grotstein, MD

I would like to address the developing interface between psychoanalysis and its derivative psychodynamic therapies and relevant neurobiological research findings, as well as some aspects of psychosocial research data, especially as they relate to the psychoses and primitive mental disorders in general and to schizophrenia in particular. Now surely is the time for the employment of a dual-track perspective (Grotstein, 1978, 1995a), which, if one were to 'use the image of a "Siamese twinship" (Grotstein, 1988), could simultaneously embrace the paradox of the separateness and interconnectedness of two or more disciplines. In developing this theme, I should like to refer both generally and specifically to emotional disorders and reflect what light neurobiological research casts on them, how psychoanalysis must modify its theories and techniques generally and specifically, and what lessons neurobiology can learn from psychoanalysis. I should also like to proffer some new metaphysical/epistemological as well as psychosocial ideas about schizophrenia that are at variance with traditional concepts held by both neurobiology and psychoanalysis.

In the title of this contribution, I have employed two key signifiers that, for me, help define the tragic uniqueness of these patients, "orphans" and the "Real." The former depicts the alien, withdrawn lostness of these patients, and the latter portrays their unique "privilege" of inhabiting a surreal, preternatural "Reality" that, as Lacan (1966/1977, 1973/1978) advised, is impervious to the filters of the Imaginary and the Symbolic. It constitutes a Kantian noumenal nightmare. I have chosen the term "orphans of the 'Real'" to depict a generic grouping of patients who seem to have awakened too early and too painfully from the protection of the passive stimulus barrier of the perinatal period or fro~ the active stimulus barrier that normally issues from bonding and attachment. Others in this group may have been unprotected from the beginning.

I consider the normal mental representation of this parental protection to be a sense of innocence about oneself and the world into which one is cast. The sense of innocence conveys a sense of initial unwakefulness to the horrors that inhere in the world of the "Real." Normally, imagination, fantasy, illusion, symbolization, and attuning relationships help to shield the infant or child from the realizations consequent upon abruption.

Children may be at risk for premature mental abruption by virtue of a constitutional endowment of hypersensitivity or hyperirritability, or of a variety of other constitutional impairments of the central nervous system, or they may be at risk by virtue of a nurturing environment that is impinging, abusive, and/or molesting - or even critically unattuned to their feelings and their need to be understood. The result is the development of an ontological orphan, a schizoid, withdrawn "true self" that compliantly abdicates in favour of its "false self" alter ego - but not before signing (unconsciously) a "Faustian bargain " that forecloses on the pursuit of pleasure and of playing in life. These children become pathologically self-conscious and self-aware. They do not play; they observe themselves trying to play. Their fate after the signing of the Faustian bargain is the inexorable feeling of being a fraud, a feeling that worsens with success or with psychoanalytic improvement. I have elsewhere described them as "feral children" (Grotstein, 1994, 1995a). I shall return to this theme.

The neurobiological revolution

Because psychoanalysis has been the senior service for the treatment of mental patients of most categories, its practitioners early on differentiated between psychoses and neuroses, later interposing the borderline category in between. Neuroses were the standard, and psychoses were compared with them in terms of the lower level of defence mechanisms and so forth. Freud himself referred to psychoses as narcissistic neuroses.

Meanwhile, those who did have the courage to explore the treatment of these sicker patients formulated theories of aetiology and psychopathogenesis that were based solely on psychological factors, implicating either a defective early environment or constitutional factors, the latter being considered originally as quantitative variations in the distribution of libido, and later of the death instinct. The former theory gradually evolved into the theory of decathexis, by which was meant that the psychotic person, particularly one with schizophrenia, suffered from an inability to maintain the cathexis of objects, not only externally but also especially internally. Freud's (1911/1958) theory of decathexis reminds us today of Janet's (1889) concept of "maladie de faiblesse," the inability to hold the integration of the mind together. Later, I shall comment on the connection between Freud's idea of decathexis and Fairbairn's (1940/1952) concept of schizoid withdrawal as a way of describing the onset of the schizophrenic experience.

By and large, however, the majority of psychotherapists who treated persons with schizophrenia and other primitive mental disorders considered themselves as belonging to the "psychodynamic" school, which meant that the patient's illness issued primarily from a "schizophrenogenic mother," which has now been elaborated into a high-affect-expressive family (M. Goldstein, 1984, 1985, 1986).

Then came the neurobiological revolution, which is still in effect. One of the major breakthroughs in this revolution was the discovery of complex neurotransmitter activity in the synaptic clefts of such major disorders as schizophrenia, unipolar and bipolar illness, borderline personality disorders, obsessive-compulsive disorders, and panic disorders. The advent of antipsychotic medication ushered in a new era in the treatment of these disorders. By regulating the dopamine in the synaptic clefts, one could alter a schizophrenic patient's vulnerability to experiencing disorganizing psychotic regressive states. A turf war developed in many countries, including the United States, for proprietary rights over how to treat regressive psychotic states. I was taught by some of my mentors never to attempt the psychoanalytic treatment of psychotic persons - and by others not to yield to the omnipotent temptation of psychopharmacological parameters. Eventually, a sobering consensus seems to have developed between the use of psychotropics for the treatment of disorganizing states and psychotherapy for the residual personality traits.

Not only does the prudent employment of psychotropic agents facilitate the psychotherapy of these patients, it has also opened up a category for psychoanalytic and psychological observation, that of the non psychotic schizophrenic patient, so now we have a clearer window into the non psychotic thought processes of these patients (Grotstein, 1989).

State versus trait and its implications

Perhaps the most clinically relevant thrust of neurobiology thus far has been from the field of psychopharmacology. Nevertheless, the unfortunate turf wars between it and psychoanalysis seem to be ebbing in the United States because, in no small measure, of enlightened psychiatry residency training programs in which psychodynamics and psychopharmacology are each seen to be clinically relevant and important. In addition, it has been recognized that the indications for the use of psychotropic medications are mainly limited to state disorders and that these medications generally have little or no effect on trait disorders - unless there may exist a subclinical state disorder that may masquerade as a trait, such as depression, panic, mania, and obsessive-compulsive disorder.

Once psychoanalysts and psychoanalytically oriented psychotherapists began to overcome their reticence and prejudice about employing psychotropic agents, it was found that, despite many failures, side effects, and complications, a significant number of patients actually did better in their analyses and psychotherapies. Not only did the peaks and valleys of ego-dystonic states of affect dyscontrol smooth out; there was also yet another reward connected to this newfound affect (and impulse) regulation, that of the raising of the patient's threshold of tolerance to stress originating either inside or outside. It was as if the proper medication served as a fuse to replace a bad fuse in a fuse box that had long been on overload. Many patients I have seen almost universally began to say; "Now I have a floor! "

The next observation was that enlightened and cooperative psychopharmacologists who worked with psychotherapists noted that many patients with primitive mental disorders who were on medication might need higher or lower dosages, depending on the therapist's absences, vacations, and so on. It finally became highly suggestive that there seemed to be a close connection between medication and the therapeutic holding/containing environment. In some cases, the need for medication ebbed when the therapeutic alliance was firmly established.

Paradoxically, the reverse has also been found on many occasions: Therapists were able to substitute themselves for the appropriate antidepressive, antimanic, antipanic, and antipsychotic medication. One reason was the therapists' belief in the effective remedial capacity of their psychotherapeutic technique. Another reason was the fact that many psychotic as well as neurotic patients resented the use of medication because of its ego-alien nature. They felt exploited by its use because it meant that their illness and its treatment were no longer under their control. Still other patients suffered from side effects that contraindicated their continued use of medication. Now psychotherapists have to pit their skills against state disorders as well as trait disorders. Strangely, this has frequently enough worked out successfully, causing us to pause to sort out such concepts as psychotherapeutically remediable versus irremediable state disorders.

Psychosocial intervention and schizophrenic outcome

It is only in recent years that the rigid dichotomy between the neurobiological and the psychosocial polarities has been softening and allowing for the possibilities of transformative interactions in both directions. Thus it has been found not only that the brain can influence the mind, but also that the mind can alter the brain's synaptic architecture. Molecular biological research provides a case in point in the experiments of Kandel (1979, 1983) and Kandel and Schwartz (1981) with the acquisition of memory in the single-celled aplasia. An even more stunning example is the changes in the synaptic architecture in patients suffering from obsessive-compulsive disorder that were achieved through behaviour modification and cognitive therapy (Baxter, 1980).

In the context of psychosocial intervention with outpatient schizophrenic patients, Moran (1994), referring to the findings of Harding, stated:

“psychosocial training in the treatment of schizophrenia challenges a long-held view of the disease as a chronic illness from which there is never any improvement, let alone recovery. Yet . . . a number of studies looking at very long-term outcome in schizophrenia consistently produces a remarkable finding: over a period of two to three decades, schizophrenia patients begin regaining capacities, and some recover wholly One conclusion is that the brain is doing something to correct itself It appears to us . . . that there is some biological recalibration. Neurologists have long said that the brain is the most plastic organ we have, the most responsive to the environment, so it shouldn't have been a big surprise The old idea of "once a schizophrenic, always a schizophrenic" just isn't true.” (p. 4)

Obviously, these conclusions deserve more careful scrutiny, and Nina Schooler, Director of the Psychoses Research Program of the Western Psychiatric Institute and Clinic in Pittsburgh, also quoted by Moran, is less sanguine about the overall findings regarding psychosocial intervention. What we can learn from this, however, is that possibilities may exist whereby the neuronal equivalent of "collateral circulation" can occur - and that the brains of all humans, including those with schizophrenia, bend to and continue to be shaped by a dialectical and dialogical discourse with the psychosocial environment.

Treating the patient with schizophrenia versus treating schizophrenia in the patient

Still another perspective emerged from the treatment of schizophrenic patients and autistic patients (particularly those suffering from Asperger's syndrome). Meltzer, Bremner, Hoxter, Wedell, and Wittenberg (1975), Tustin (1990), and others who worked with these latter patients reported significant successes with psychoanalytically informed treatment. Yet we have good reason now to believe that autism, like schizophrenia, is a genetically determined dementia.

What role, if any, does a psychoanalyst have in the treatment of these patients? One satisfying answer that seems to have emerged is that the psychoanalytically informed psychotherapist is justified in attempting to treat selected patients who suffer from mental illnesses in which neurobiological factors are operant; that is, the therapist may be able to treat a patient who is schizophrenic even though the therapist may not be able to "analyse" the schizophrenic process per se. The criteria here would be between putatively remediable and irremediable disorders, to which I alluded earlier. Because considerations for using psychoanalytic treatment for allegedly unanalysable conditions have often encountered ideological rather than scientific resistance among psychoanalysts, it has frequently been difficult for enthusiastic and dedicated therapists to venture into this area. We must also remember that all patients, irrespective of diagnosis or prognosis, deserve to be listened to. In the course of interaction between therapist and patient, a "third language" seems to develop, one that alchemically alters, blends, and distinguishes the uniqueness of the couple's discourse. Ideally, it constitutes personalized psychoanalysis, but it also frequently includes supportive psychotherapy.

The impact of infant development and trauma research on psychoanalysis

Another significant factor in the mind-brain dialectic emerged from the extensive research in infant development, particularly neurodevelopment, and in empirical studies on child and adult survivors of child abuse and molestation. Schore (1994), in an elegant monograph on neural development, demonstrated that maternal (and paternal) affective attunement is necessary for the optimal unfolding, development, and integration of the infant's and toddler's "neural wiring." In other words, the mother's ministrations to her infant are requisitely catalytic for neuroblasts to reach their ultimate specific target location.

Stone (1988) has reviewed the borderline syndrome from the perspective of chaos (complexity) theory and trauma research. In that contribution, he cited data from trauma research suggesting that hyperirritability is the "red thread" running through that disorder. I should like to expand on his thesis to the point of considering hyperirritability and its analogue, hypersensitivity, as a significant pathogenic factor in schizophrenia and many other primitive mental disorders. It seems to be a unifying factor that should be considered either as primary, from the perspective of constitutional (hereditary and/or congenital) factors, or secondary to perinatal environmental trauma.

One significant factor that has emerged in this regard is that a traumatic early environment seems to inscribe itself in the infant/toddler/child's "hard wiring" and to persevere as the "complex posttraumatic stress disorder" (Herman, 1992). Future research must untangle the complexity of the significance of environment-related brain patterns, on the one hand, and, on the other, significant constitutional factors, such as the palisading effect of the sacrificed neurons that failed to achieve their target destiny in the hippocampal cortex of persons with schizophrenia (Scheibel & Kovelman, 1981), thereby presumably impairing their processing of emotional memory.

Disorders of self-regulation ("neurodynamics")

Several authors who have investigated varying subjects, such as psychosomatics, alexithymia, and trauma, have begun to think of some mental illnesses in terms of disorders of self-regulation (Grotstein, 1986a; Krystal, 1988; Taylor, 1987). Sacks (1989) applied the term "neurodynamics" to the behaviour of the patients suffering from Tourette's syndrome.

Perhaps this concept could be applied to schizophrenic patients. Given the probability that these individuals suffer from a dementia, they have some conscious and/or unconscious awareness of this handicap and compensate for it as well as they can. They become locked into a rigid adjustment ritual, not unlike the concrete attitude described by Kurt Goldstein (1943) for brain trauma, that is characterized by an intense fear of change. A negative therapeutic reaction to progress can take place because of the patient's fear of the incompensable loss of a comforting self-sameness.

This reaction can be understood in conventional classical or Kleinian psychodynamics, but, on the neurodynamic level, one can understand that these patients seem to have an inner idea about their psychological "modulus of elasticity" so that any change is anticipated as catastrophic (Bion, 1970). So much of the behaviour of schizophrenic patients can be understood as adjustments within the perimeter of their felt limitations.

The actual neuroses (and psychoses)

In the preceding section, I introduced the concept of disorders of self-regulation or neurodynamics and suggested that these disorders are governed by principles that differ significantly from psychodynamics and yet overlap with them. I should now like to hint at a subject introduced long ago by Freud (1895/1962a, 1895/1962b, 1895/1962c, 1950/1966) that adumbrated this notion, that of the actual neuroses. Freud believed that these conditions represented pure overflow of libido, were not psychoneurotic (i.e., did not possess unconscious meaning), and were due 'to the uncompleted sexual act. Despite the naiveté of his conception, he nevertheless created an entity that has special bearing on a wide variety of mental disorders that span the mind-brain dialectic. I believe that the schizophrenias, bipolar illnesses, hypochondria, panic, anxiety disorders, obsessive-compulsive disorders, attention-deficit disorders, and some other conditions belong to the category of the actual neuroses/psychoses insofar as they consist of pathological entities that are originally non psychodynamic.

A complete review is beyond the scope of this contribution, but I want to headline some of the more relevant neurobiological considerations. Although identical-twin studies have established the genotype propensity for vulnerability to schizophrenia (Kety, 1976; Kety & Ingraham, 1992; Kety, Rosenthal, Wender, & Schulsinger, 1971; Murray, Reveley, & McGuffin, 1986), longitudinal at-risk studies have been able to sort out the onset of early sensorimotor and perceptual-cognitive vulnerabilities (Erlenmeyer-Kimling, 1976a, 1976b; Erlenmeyer-Kimling, Golden, & Cornblatt, 1989; Fish, 1977, 1987; Fish & Hagin, 1972; Fish & Orloff, 1984; Kestenbaum, 1986).

Kety (1972a, 1972b, 1979) was the first to study abnormal dopamine production in certain neurotransmitter systems of schizophrenic patients, while Buchsbaum (1977a, 1977b) and Buchsbaum and Haier (1987) reported on abnormal EEG findings. Meanwhile, a vast array of idiosyncratic neuropsychological deficits were found in these patients: (1) defective attention and "gating" for sensory data, particularly of the visual pathway (Freedman et al., 1987; Harrow & Marengo, 1986; Harrow, Marengo, & McDonald, 1986; Harrow, Marengo, & Ragin, 1986; Marengo & Harrow, 1987; Marengo, Harrow, Lanin-Kettering, & Wilson, 1986; Nuechterlein & Dawson, 1984); (2) thought disorder (Andreasen, 1982, 1984, 1990; Grove & Andreasen, 1982; Holtzman, Parham, Prohaska, Oster, & Leahey, 1983); (3) information processing (Callaway & Naghdi, 1982; Saccuzzo & Braff, 1986; Saccuzzo, Larson, & Rimland, 1986); (4) language disorder (Crosson & Hughes, 1987); and (5) defective orienting response (Bernstein, 1969, 1987).

Feinberg (1987) demonstrated that in adolescent schizophrenic patients, a massive reduction in the amplitude and duration of the delta EEG waves of deep sleep (Stage 4) occurs, with a concomitant decline in cerebral oxygen consumption. He believes that this mechanism is genetically controlled. Feinberg concluded: " A defect in this (presumably) genetically controlled process might impair mechanisms of neural integration and thereby produce the illness in at least a subgroup of patients with the schizophrenic syndrome" (p. 507).

Anscombe (1987) believes that persons with schizophrenia suffer from a disorder of consciousness; that is, they have "an inability to sustain an intentional focus to attention. Attention is captured by incidental details in the schizophrenic patient's environment, and this gives rise to a spurious sense of significance" (p. 241). Abnormal information processing in schizophrenic patients has been reported by Traupmann, Berzofsky, and Kesselman (1976), Schneider and Shiffrin (1977), Shiffrin and Schneider (1977), Braff and Saccuzzo (1981), Broga and Neufeld (1981), Baribeau-Braun, Picton, and Gosselin (1983), Bernstein, Riedel, Pava, Schnur, and Lubowsky (1985), and Bilder, Mukherjee, Rieder, and Pandurangi (1985).

Whereas the original neurobiological research in schizophrenia emphasized the pharmacology of dopamine, the newer research emphasizes the neurocognitive aspects of the disorder, such as (1) a deficiency of working memory (Goldman-Rakic, 1993), (2) an impairment of willed action (Frith, 1989), and (3) a deficiency in processing and integrating information (Knight & Fischer, 1992).

The impact of neurobiology on the psychoanalytic treatment of schizophrenia

Ever since the last century, there have been two differing theories of brain pathology: (1) the specific localizing theory of Broca (1878), and (2) the more generalized, disorganizing theory of Hughlings Jackson (1884) and Freud (1891/1953, 1895/1962a, 1895/1962b, 1911/ 1958, 1950/1966). This differentiation is of some relevance for our subject. Discrete lesions (neurotransmitter dysregulation disorders) in the central nervous system may cause specific distal neuronal target disorders or may lead to a more generalized compromise of the level of functioning of the central nervous system, akin to Janet's (1889) "maladie de faiblesse," signifying an overall weakness and consequent inability of higher hierarchical levels of the central nervous system to maintain their hegemony over lower levels. Consequently, we must consider at least two different kinds of neurologically induced psychopathology, the specific and the general. Thus, in many of the schizophrenias, whether it be a non-psychotic schizophrenic patient (Grotstein, 1986b), a schizotypal patient, or a paranoid schizophrenic patient, we must consider both (1) the effects of specific brain influences, and (2) the overall effect in compromising the level of functioning of the patient.

The differentiation between the psychotic and the non psychotic personality

A universal finding of therapists who have treated patients with schizophrenia and other psychotic disorders is that these patients, more frequently than not, candidly reveal in the most articulate way their experience during their psychotic break of there being a lucid, sane self that had been clearly aware of what was happening during the psychotic break but that felt totally unempowered to operate on the patients' own behalf. Katan (1954) and Bion (1956) commented on this well-known dissociation. These experiences seem to suggest that the neurobiological findings may speak more to state rather than to trait psychopathology, even though trait vulnerability may have been the key marker for the state disorder. In other words, no matter how neurobiologically impaired a patient's brain has become - up to a point - there exists a sane, reality-testing self that bears helpless witness to the debacle.

What I am suggesting, even in light of my paradoxically differing statements earlier, is that we must avoid concretising the relationship between brain pathology and psychopathology. In other words, is there really a one-to-one relationship, or are there many variables in the equation that we need to consider?

A related question is whether the clinical entity of psychosis is a neurobiological event or a strictly psychological event. What I am getting at here is the differentiation between, for instance, hypomania and hypomanic psychosis, or psychotic and non-psychotic schizophrenia. Although it is undoubtedly true that neurobiological substrates predispose the affected patient to psychotic vulnerability, may it not be the case ultimately that psychosis is always a psychological response to the patient's experienced breaking point of integrative strain? That is, psychosis is the last possible exit from the emotional ownership of the self as the patient disembodies from his or her very existence and undergoes what amounts to the fantasy of a Faustian bargain to purchase the illusion of safety at the expense of "going-on-being."

Accommodations to neurobiology in the psychoanalytic treatment of the psychoses

In approaching this highly relevant subject, let me first refer to the important gains made originally by behaviour modification and later by cognitive therapy in the treatment of a number of disorders, including panic, unipolar and bipolar illness, and obsessive-compulsive disorder. In his positron-emission studies of the treatment of obsessive-compulsive disorder, Baxter (1980) found that behaviour modification was not only as effective as psychopharmacological treatment for this entity, but that it also reversed the specific brain lesions that underlay the disorder. Similar findings have been demonstrated by the employment of cognitive psychology. It is my belief, born tentatively from clinical experience with my own cases and some I have supervised, that psychoanalysis and psychoanalytically informed psychotherapy could conceivably do the same as behaviour modification and cognitive therapy in the same disorders that they approach. Because these two other approaches are essentially object-relational and verbal in their stance, as is psychoanalysis, then surely psychoanalytic technique could, if appropriately aimed in similar ways, accomplish what these other entities accomplish.

A thought occurred to me while reading a paper on the pathogenesis of cancer; it described how the cancer cells purloin their host's vascular system for their own growth. Could it not be that certain psychiatric disorders that have either a primary or secondary neurobiological basis seek to become ratified and enfranchised as legitimate psychodynamic entities, whereas they may be neurobiological "impostors" who seek to ensorcell the naive psychodynamic therapist into thinking they are authentic emotional entities, but all the while they are, at least initially, meaningless neurodynamic breakdown products from the brain's overloaded "fuse boxes"?

If this formulation has merit, and I personally believe that it does, then the psychodynamic therapist could perhaps handle schizophrenic patients, for example, similar to how patients suffering from other related disorders would be handled. First, the therapist would refrain initially from giving dynamic meaning to certain symptoms and behaviours; second, the therapist would approach these patients with the offer of a "quarantine"; and, third, the therapist would analyse their experience of possessing these entities to which they have succumbed and turned over their "power of attorney."

Put more simply, similar to the practices of the cognitive or modification-modification therapist, the neurobiologically informed psychoanalytic psychotherapist can help panic patients to mentally "quarantine" their panic and to understand that they are suffering from (1) a low threshold of tolerance to affective disruption because of (2) an inadequate fuse in their cerebral fuse box; in addition, these patients must (3) be able to teach themselves to (4) anticipate their veritable seismic disruptions, (5) decentre themselves from them (disown their personalness while still owning their existence), and (6) withdraw their trance-like submission to and "power-of-attorney" from these neurobiological would-be demons, which are only neurodynamic happenings. In treating monopolar, bipolar, and panic disorders, one often runs into patients who will not or cannot (because of side effects) take appropriate medication. If the psychotherapist in these cases can be aware - and help these patients become aware - that, in addition to their psychodynamics, they are suffering from an acute intensification of the experience of these feelings because of a defective affective "fuse box" somewhere in the neurotransmitter system, one can frequently achieve results similar to those achieved by cognitive and behavioural therapists. In schizophrenic patients, the therapist may have to consider such varying weaknesses or deficits as the following: (1) affect instability, (2) difficulty in focusing and in maintaining an idea, (3) flooding of ideas because of poor "gating," (4) difficulty in sorting out ideas and in giving them appropriate priorities, and (5) predisposition to a frontal dyscontrol syndrome. This proposed alteration in psychoanalytic technique is one of focus, not of the use of parameters. To facilitate it, the psychoanalyst must become reasonably sophisticated in neurobiology, psychopharmacology, and especially neurocognitive research to gain some idea about what the patient is suffering from. It is one thing to say that these patients cannot think properly because they have internalised an attack by their parents that, in turn, attacks their own thinking processes. It is quite another to say, "1 think you want me to know how bad you feel when you have evidence that you cannot think or perceive with the same agility as others, how ashamed you must feel to think of yourself as incompetent. Yet, because your feelings of being deficient are so extreme and polarized, you psychologically render yourself totally handicapped and then try to escape from it into more and more self-abandonment-and fraudulently repair your self-esteem by becoming delusionally arcane, mysterious, and omniscient." This model interpretation is merely an example of a countless number of interventions that can conceivably help patients familiarize themselves realistically with the specific nature of their disorders and their clinical manifestations, and then help the patients quarantine them, anticipate them, and defuse their felt omnipotence. In other words, this technique is similar to the practice of doctors in rehabilitative medicine who have to help their patients accept, adjust to, and work around their handicaps. Thus the theoretical rationale for the application of a neurobiologically informed psychoanalytic technique would be either (1) to help reverse the neurobiological handicap through interpretive intervention, or, failing that, (2) to work more effectively with the available patient who is suffering from an unalterable dementia. The former aim may be overambitious and overhopeful but nevertheless worthy of consideration. The latter may be more practicable. We must also remember that the current state of knowledge in neurobiology is unable to inform us of the discrete nature of the relationship between brain pathology and psychological outcome. As we recall, there have been two traditional concepts in this regard: (1) the specific one-to-one Broca-type (1878) relationship based on an immediate lesion-symptom correlation, and (2) the Hughlings Jackson (1884) - Freud (1891/1953, 189511962a, 189511962b, 1950/1966) conception of hierarchic-level default where an injury to the central nervous system causes a regressive reorganization on the next lower level of cerebral integration. Put more succinctly, we do not yet have the data to predict who is irremediable to modified psychoanalytic psychotherapy. Is it a practicable idea to select for early mother-infant intervention those infants and children at risk for later schizophrenic breakdown, not only to help inadequate mothers become adequate ones, but also to help putatively "good-enough mothers" become extraordinary mothers so that they can deal with their troubled children's distress with optimum effectiveness? Furthermore, would it not also be a good idea to select for psychoanalytic psychotherapy young symptomatic children-at-risk to help them develop the brain/ mind equivalent of "collateral circulation " as a bypass to their potential or actual dementia-in-place?

Orphans of the 'Real'

The concept of 'reality'

I would now like to proffer some comments about newer conceptualisations of schizophrenia. First, I would like to discuss the schizophrenic person's relationship to reality. All psychoanalytic schools seem to distinguish between internal and external reality, the latter of which seems to have been taken for granted as understood and agreed on by everyone. The former is probably better expressed as "personal reality," in contrast to the latter, which could be restated as "shared reality." First of all, as Palombo (1987,1993) pointed out, patients suffering from primitive mental disorders in which there is a problem with perceptual-motor functioning tend to have difficulty with the transition between the personal and shared domains. Schizophrenic patients tend to be ashamed of their mental functioning and therefore keep it hidden as much as possible. Yet because their shared reality depends on input from their personal reality (and the reverse), there is always a felt danger to them of being exposed and humiliated about their reality orientation and processing.

The perspective that I have just proffered is in line with the more traditional notion that the person with schizophrenia has a defective relationship to reality. From the Lacanian perspective, we get an entirely different point of view. Lacan (1966/1977, 1973/1978) distinguished three registers of thought: (1) the Imaginary, (2) the Symbolic, and (3) the Real. Normally, all individuals perceive themselves and the objects of their external and internal reality through the registers of the Imaginary and the Symbolic. Each constitutes a kind of filter, the former a visual one and the latter a linguistic-conceptual one, each of which encodes our realizations. The Real is un-Imaginable and un-Symbolisable. It just is! The Real, in other words, constitutes Kant's (1787/1867) "thing-in-itself." From this point of view, psychotic persons see the Real only because of the defectiveness of their filter of the Imaginary and the Symbolic.

My own reading of Lacan on this point has caused me to reflect on a number of patients who seem to have been "born into the 'Real"' as ontological "orphans" whose awareness of distress exceeded their tolerable threshold allowances, whether because of inborn givens, perinatal factors, unusual sensitivities, or whatever. They seem to have been denied the protective blanket of: (1) inborn thresholds, (2) passive stimulus barrier, (3) the mother's facilitating holding environment (Winnicott, 1960/1965b), with its container function for its mental and physical "content" (Bion, 1962), (4) background presence of primary identification (Grotstein, 1980), or (5) the matrix (Ogden, 1986). These individuals seem to have subtle to profound difficulties in engaging or being engaged (attached) to and by (bonded by) their mothers. They often seem to have engaged in double lives as true and false schizoid selves. What has recently attracted my attention is their propensity to be "self-conscious," by which I mean that they seem almost literally " beside themselves. "

The concept of "orphans of the 'Real"' is meant to apply both tightly to the outcomes of critically disadvantaged children and also loosely to some portions of all individuals in a way similar to Fairbairn's (1940/1952) characterization of being "schizoid," Winnicott's (1960/1965a) "true" and "false" selves, and Kohut's (1971, 1977) concept of the narcissistic disorders (disorders of the self). Most basically, I characterize these patients as having entered into states of misrecognition (Lacan, 1966/1977) or "disappearance" through three differing but coexisting mechanisms: (1) projective identification, (2) introjective identification, and (3) alienation (depersonalisation).

One patient in this category recently put it well when she stated, "When I was a child, I didn't play. I watched myself trying to play the way other children did. I learned to imitate them very well, but I always knew, and still know, that I'm not one of them." This patient also demonstrated another trait that I have found characteristic of this class of individuals. She quickly learned to read as a child, and she found herself getting so immersed in books that she became virtually lost in the characters she was reading about. To say that she had gone into - and still does - a state of projective identification with the fictional heroes, heroines, and protagonists does not do sufficient justice to the translocated otherness of her existence when she reads. She tells me that, when she reads fiction, she becomes transported into the work and, for all the world, lives there! This particular patient was schizophrenic when she first came to see me, but now she seems to have evolved to the level of a normal person leading a normal life. Yet, when one looks under the surface, one still can see the residue of an altered thought process, one that is non psychotically schizophrenic.

In another context, I have discussed this group of patients - particularly the more extreme, traumatized ones - as those who have seemingly "died" as children and reformed along altered, imperceptible lines. In analysis, they frequently reveal that, to be safe, they had unconsciously signed a Faustian bargain with a part of themselves. The bargain was to die emotionally so as to "stay alive," but at the price of caring.

The sense of reality and reality testing in schizophrenic patients

We have long taken for granted that schizophrenic persons suffer from a defect in reality testing. Foucault (1961/1965), in reviewing the history of how mad individuals have been conceptualised over the centuries, pointed out how our opinion of them has deteriorated since the Renaissance, when they were thought to be wise fools who also revealed our own foolishness. From the time of the Enlightenment up to and including modern times, they have been subjected to the ignominy of the one-dimensional medical model and the hegemony of logical-positivistic science. From the standpoint of empirical psychiatry, they are considered to be suffering from various forms of a delusional psychosis and therefore from poor reality testing. From the psychoanalytic standpoint, they have been considered primitive and prone to cataclysmic libidinal regressions. Kleinians consider them to represent the quintessence of omnipotence.

In a remarkable new work, Louis Sass (1994) has attempted to reinterpret schizophrenic symptomatology from a refreshingly new yet odd camera angle as an uncanny twin, as it were, to the epistemological and metaphysical obsessions of philosophers. He develops his thesis by comparing the Denkwurdigkeiten of Senatspriisident Daniel Paul Schreber with the antiphilosophy of the great philosopher, Ludwig Wittgenstein (1933-1935/1958). Sass believes that philosophers, like schizophrenic individuals, have a propensity for abstraction, alienation, and detachment from their bodily experience. He believes that the delusional experiences of schizophrenic persons are far more complicated than hitherto thought, that they differ significantly from those of other psychotic individuals (e.g., those with manic-depressive illness), and that there have generally been too many misconceptions about them altogether. Sass believes that these patients do not have a propensity for libidinal regression, nor are they so estranged from their reality testing.

In his careful reading of Schreber's Memoirs, Sass demonstrated over and over again that, while Schreber believed he was experiencing what we would term bizarre phenomena, he, too, was simultaneously aware of its strangeness vis-à-vis the credibility of normal people. I think that we now distinguish between the psychotic and the non-psychotic schizophrenic person. Whereas in the former case there always seems to be a normally observant personality lurking impotently but realistically in the background, in the latter case, the patient may be in contact with many putatively bizarre notions (what we formerly called "encapsulated delusions") but seems at the same time to have empathic sensibilities about our differing credulity.

Altered consciousness in schizophrenic persons

In comparing Schreber's case history with some of the philosophical ideas of Wittgenstein, Sass referred to the latter's concept of solipsism, the notion of the self-generational origin of thoughts and the self-referential nature of all events. At the extreme, it is a way of understanding the schizophrenic person's ideas and delusions of reference. Normally, solipsism is the perspective that characterizes how the infant "creates" the world that it continuously discovers, as Winnicott (1971) pointed out.

The infant's solipsistic perspective, which Klein (1946/1952, 1955) described from the angle of projective identification, gradually transforms into secondary process, logical thinking that considers the independence of external reality. While solipsism is in operation, however, it seems to create an ambiguous, dissociative mystery in which, on the one hand, the subject creates the event or the objects in the event, and, on the other hand, feels totally impotent toward the object's "creation" and effect on the subject. This latter phenomenon is termed transitivism, an experience that is characteristic of schizophrenic thinking and one that has been explained in detail by Klein's conception of projective identification followed by unconsciously anticipated projective counteridentification by the object. The quintessential reminder of the extreme of this process is Tausk's (1919/1933) phenomenon of the "influencing machine," that depersonified, now-mechanistic residue of the patient's former vitally alive self.

Solipsism, which can also be understood as self-referentialism, autochthony, and/or syncretism, becomes bizarre and preternatural when it is combined with the other schizoid-schizophrenic propensity for disownership of the self, disembodiment, or disappearance as a self. Under this latter condition, the mind becomes deprived of the ordinary echoes, confirmations, and reinforcements of the harvest of intersubjective discourse, and instead finds itself trapped in another dimension of time and space, trapped in an echo chamber without reflection, which could all the while be a virtual carpet factory in which the cries of dying remain mockingly unheard. A transformation ultimately occurs in which the self now feels itself to be involuntarily transported to the numbness of pain, but at the cost of the Faustian bargain - to be safe but insane.

A profound and extensive series of dissociations then takes place that ushers in a dreadful scenario of numbness to the nameless dread, plummeting into the "black hole" (Grotstein, 1990a, 1990b, 1990c, 1991), the sudden appearance of "enlightenment" (on the black hole's "event horizon") and absolute certainty about all the thoughts and feelings that had hitherto constituted the patient's transitivistic terror as victim of an altered reality and the fears of persecution by reconstituted "others." But now the patient seems to be helped by the enlightenment of his or her reconstruction: The patient now knows who is doing this terrible thing to him or her - and why! The "why" gets into a reconstructed narcissistic, martyred life-theme in which the patient then enters into a psychotic phantasmagoria of religious themes, including an identification (concordant, complementary, and oppositional) with the deity and with his "only begotten son," Jesus Christ. I have visited the closed units of mental hospitals all over this country and others and have never found an atheist. Instead, I have found various poignant replays of the New Testament - even if the patient is orthodox Jewish! With these patients, the sense of consciousness is altered, and they experience a serious division in the sense of consciousness in which there develops the infinite sense of consciousness becoming conscious of itself becoming conscious of itself becoming conscious. Finally, there develops the eerie sense of consciousness.

Theoretical alterations to facilitate treatment of schizophrenia

When one speaks of the psychoanalytic treatment of schizophrenia or, for that matter, of any other disorder, one presumes that psychoanalysis is a single entity both in terms of theory and technique. As we all now realize, however, psychoanalysis, as Bion (personal communication, 1970) pithily observed, has suffered the enactment of the myth of the Tower of Babel. If I were to list the psychoanalytic schools in practice today, I should include the following: the orthodox Freudian, the classical Freudian (distinguishing between American and European conceptions of "classical"), developmental, Kleinian, Bionian, object relations (British Independent school versus American school), interpersonal, relational, self psychology, intersubjective school, Lacanian, Jungian, and Adlerian, for the main part and perhaps a few others.

Space limitations proscribe an explication of the pertinent values of each school relevant to the treatment of schizophrenia. Let it suffice to say that each school has attempted to treat these patients and has reported some success over the years. In two recent works, the authors have reported their experiences over many years of successfully treating psychotic - principally schizophrenic - patients in which they used psychoanalytic as well as neurobiological-psychopharmacological and other ancillary interventions (Jackson & Williams, 1994; Robbins, 1993).

In line with the thoughts just discussed, I want to reiterate a relevant idea about psychosis that I have offered in other contributions. Traditionally, psychosis is considered a disorder of reality testing and, by inference, of secondary process (Freud, 1911/1958). It is my contention that these patients suffer from a defect in primary process so that the phantasmal underpinnings of their reality collapse or implode because of this foreclosure of their personal mythic blanket of ultimate protection. Put another way, they are robbed of the blessings of dreaming! I believe that the concept of "the Real" can be joined to Freud's (1911/1958) concept of "decathexis," Federn's (1952) concept of "defective ego boundaries," Stone's (1988) concept of "hyperirritability," and Sass's (1994) and my (1995b) concept of "solipsism" to fashion a workable synthesis of psychoanalytic ideas that have value for the treatment of schizophrenic patients.


In an earlier contribution, I (1978) applied mathematical theory to the concept of psychic space. I believe that some of the conclusions I arrived at there are relevant for this subject. Briefly, the normal child who learns how to play with space and in space (Winnicott, 1971) finds himself or herself in the third dimension and in the dual track. That is, the child can see the difference between fantasy (illusion) and reality and also can see alternatives in the length, breadth, and width of reality. All mental illness predicates the inoperativeness of play, that is, there is a foreclosure or lack of development of the third dimension and the dual track (Grotstein, 1995a). That is, patients having mental illnesses of whatever category are incarcerated in psychic dimensions less than three, usually the first dimension of absolute "either/or." Paranoia characterizes the first dimension, and psychosis the zero dimension where the walls of psychic space and time collapse to infinity. To me, this is what Lacan really meant by the Register of the Real!

I believe that neurobiologically informed psychoanalysts who have also "retooled" themselves in post-modern hermeneutics, solipsism, and intrasubjectivity, as well as its interpersonal analogue, intersubjectivity, and also in cognitive therapeutic skills, can be reasonably effective in the treatment of patients with schizophrenia and other primitive mental disorders. In other words, as therapists intersubjectively engage with their patient's intrasubjectivity, they begin to intuit and empathize with the patient's unusual difficulties participating in treatment. In tracking and dealing with these handicaps, the patient's analysis can be facilitated. I recommend interpretive quarantining and defusion of the omnipotent, hypnotic power of the delusional internal objects that have held such sway with these patients.



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This article is based on a presentation at a Menninger Continuing Education conference, "Psychodynamic Approaches to the Treatment of Psychotic Disorders:

American and French Perspectives," Topeka, Kansas, June 9-11, 1994. Dr. Grotstein is a clinical professor of psychiatry at the UCLA School of Medicine and a training and supervising analyst at the Los Angeles Psychoanalytic Institute and the Psychoanalytic Centre of California, Los Angeles.


(1) In an earlier contribution, I (1990c) referred to this patient as having experienced and dreamed about the "black hole."