Review - Clinical Schizophrenia & Related Psychoses ( 2021) Volume 15, Issue 4
Psychosis and Dissociation in the Psychodynamic EvolutionFulvio Marchese*
Fulvio Marchese, Department of Psychiatry, AOUPP Giaccone Palermo Psychologist Analyst CIPA, Palermo, Italy, Email: [email protected]
Received Date: Jun 08, 2021 / Accepted Date: Jun 22, 2021 / Published Date: Jun 29, 2021
In the following pages we will try to discuss the stratified idea about psychosis seen as disorders of the neuro-cognitive system, looking at both the etiopathogenesis and treatments. We will do so by comparing the theoretical and biographical aspects of two amongst the greatest authors of the 1900’s about psychosis: C.G. Jung and M. Klein. Once again, we will try to demonstrate that psychosis involves an extremely meaningful psychological meaning, which is crucial in any therapeutic approach in order to improve the prognosis. Following the lead of J.W. Perry, we will try to claim that psychotic disorders are particular psychotic manifestations that originate in the emotive-affective dimension of the human experience, whose neuroanatomical-functional localization can be found in specific sub-cortical regions of the brain, and that they only display the thought alterations as we know them in a phenomenic manner. Lastly, once again inspired by the comparison between Jung and Klein, we will propose a comparative diagnostic-functional hypothesis between the dissociative and the psychotic conditions.
Dissociation • Treatment of acute psychosis • Affective trauma
Starting from the origins of modern psychiatry, the most well-known and fascinating symptoms of psychoses – delusions and misperceptions – have been the subject of great interest and in-depth analysis, both in taxonomic – descriptive terms (Jaspers, Kraepelin & Bleuer) and on an interpretative level, with the purpose of attributing a psychological meaning to them (Freud, Jung & Janet) [1,2]. Over time, the descriptive approach has essentially used up all of its argumentation (psychotic symptoms are the same as always!), whereas the psychological interpretative approach has never really been able to prevail, due to the great psycho-pharmacological revolution started in the 1970’s, which caused a loss of psychological and psychodynamic interests in psychotic disorders, especially concerning the etiopathogenetic aspect.
With this due foreword, however concise and unsatisfying but on the whole quite representative, after almost a century and a half of studies and debates, we can state that the most evident aspect of the acute psychotic condition is the alteration of the process of coding and decoding reality that the patient shows (both in the confrontation with others’ opinion and in the premorbid condition), a sort of short-circuit of the ability to interface between internal and external reality-the latter having worked well up to then . Furthermore, we can state that modern psychiatry, thanks also to the recent contribution of neuroscience, considers psychotic syndromes primarily as disorders of the higher cognitive functions (impairments of the tertiary process), to which we should add the dysfunction of the sense- perception, so essentially the alterations of normal thought functions and information processing mainly related to neurobiological-genetic factors.
In our view, this vision is not enough explanatory of the complexity of the psychotic phenomenon. Our declared intention is to retrieve the psychological and relational premorbid aspects of psychotic conditions and to create a bridge between functional neuroanatomy, evolutionary psychopathology and psychology of psychosis.
At the origins of psychosis: The contribution of analytical psychology
In the history of psychiatry and of the theories of the unconscious psychodynamic, Jung can be considered as the first author to have shown interest in the psychological aspects of psychotic disorders. Perhaps we ought to be even more precise: At the beginning of the twenty first century, Jung’s observation and systematic study of psychoses represented the greatest scientific-experimental contribution to the newly born psychoanalytic theory. In fact, Jung imposed himself on the international psychiatric scene of the time, with his well-known word association experiment first conducted on normal subjects and in a second moment on psychotic patients in 1906. Which will be the results of the experiment? Jung was to conclude that psychotic patients, on a psychological level, show some thematic areas characterized by a strong unexpressed emotional load. Years later after that study, one of the main aspects of the Swiss author’s contribution to psychological sciences was to take shape: the “Feeling-toned complex theory” . It is important to underline how the concept of feeling-toned complex, resulted from the study of psychotic patients, nowadays is still the object of deep analysis and clinical use; moreover, neuroscience has demonstrated its scientific evidence both in psychotic patients and in healthy individuals [5,6].
Although Jung had not denied the possibility of neurobiological cofactors at the base of psychotic condition, such aspects always remained quite marginal in his studies: He was mainly interested in the emotive- affective aspects, to the point that in his Psychology of Dementia Praecox he stresses the correlation between events emotionally loaded with subjective meaning and the onset of psychotic symptoms , which is similar to the stress-vulnerability-coping vision about the onset of psychotic disorders . In his writing, the Swiss author reports a few clinical examples supporting said scientific-hermeneutic hypothesis. But Jung goes even further, to the point of stating that the most characteristic symptoms of psychoses, delusions and misperceptions, are psychic productions dense with meaning and expressed through an unusual, crepuscular, surreal language. Jung was to make his greatest effort on the subject of psychoses in 1912, the publication year of Symbols of Transformation, where the image-rich language produced in states of alteration of consciousness, including the psychotic state, is analyzed in all its forms, sectioned, interpreted and eventually recomposed in order to be compared to the dreams language: From senseless to symbolic language; psychosis gains a new status in the 1900’s world of psychiatry but there is still a lot of work to be done. From that moment on, an endless silence begins on a clinical and a psycho- therapeutic practice level. Jung was only to go back to psychoses in the 1950s, going so far as to say that over time he convinced himself of the “curability and recovery from schizophrenic disorders” .
Let us take a step back. The publication of Symbols of Transformation was a fundamental work for Jung, both because of the study of the symbolic language expressed in the states of altered consciousness and for the concept of libido. As we already know, for Jung the libido is not only psychic energy of sexual derivation as it was for Freud, but it is instead psychic energy in the strictest sense of the word, that can manifest itself through sexuality as well as through many other ways, including psychotic condition. The affirmation of his thought at that time represents for Jung a diriment transition: Shortly after, the rift with Freud was to come and, as a consequence, the separation from the psychoanalytical movement as well. Under some aspects it was a pointless effort because, as we have previously stated, his thought had not influenced the psychiatric world of the time much. Jung himself confirmed it in 1953, when he wrote the preface to a book about psychosis written by one of his young American students, John Weir Perry. In those few pages, the by then old head of school, goes back with a nostalgic mood to the origins of his own professional experience, he revisits his relationship with Freud, he reaffirms his ideas he had long been convinced of about psychoses and the symbolic language. Jung ends that preface in the hope that the work of Doctor Perry could reawaken the interest of psychiatrists in the psychological aspects that emerge through psychosis from the unconscious. Perhaps, it was even that experience that only a few years later led him to affirm that schizophrenia can be healed. It is not easy to give an answer. Let us now try to get to know that young American student better, and to clarify why he is the true inspiration behind these pages.
Anyone finding themselves reading one of Perry’s works will soon realize that it is an absolutely discordant voice. Perry is a hermeneut (like his teacher), he speaks from experience, and he said things that had never been said before, nor after, about psychoses. Things that, after more than forty years from their publication, are still very far from being taken on board by the scientific world. The most relevant concept Perry expressed is that the psychotic process is a spontaneous process of psychic reorganization. It is a natural self-healing process . The biggest problem is adapting the healing systems to the process. In The Far Side of Madness (1974), he writes that the true pathological aspect does not stand in the psychotic manifestation of symptoms, but rather in the premorbid psychological functioning. According to Perry, people who over time will develop psychosis are characterized by a deep yet subtle affective inhibition, in which part of the emotional world is trapped in the psyche, under strict unintentional control of consciousness. In other words, a dissociated functioning. The explanation of this process is described by the author in an inevitably speculative manner, based on the historical- anamnestic reconstruction of his patients. He focuses on the epigeneticrelational aspects, emphasizing how psychotic patients have lived relational experiences where they were “imposed” a type of psychological functioning in which only part of the affective-relational experiences could be recognized and expressed, whereas another part was denied both by the context and, with an adaptability process, by he who will develop psychosis over time . Relational ambiguity and psychological contradiction would therefore represent the most fertile ground for the development of pre-psychotic personality. After all, this idea is super imposable on the concept of paradoxical communication of Watzlawick (1967), of Jungian’s education as well, who underlines how sometimes, inside family systems, some individuals could find themselves exposed to messages so dense of contradictions that they cannot be assimilated with a logic and sensed construct: The cognitive-cortical functions are therefore compromised and, although for adaptability purposes the message could still be codified as acceptable from a logical-relational point of view, under cognition the natural feeling-toned complex related to it starts to fill up with inexpressible psychic energy, setting the basis for future symptomatic explosions .
Historically, the affective-relational aspects of psychoses have never been given much importance as meaningful etiopathogenetic elements in the psychiatric domain. Until not long ago, despite the important contributions of the Jungians and of the systemic-relational visions [10,13-15], the medical psychiatric world was mainly interested in the organic aspect in order to understand the origins of psychoses, and in the symptomatic remission through pharmacotherapy as the best achievable therapeutic outcome. However, recently the wind seems to be changing, as some meaningful works on the correlation between infantile psychoses, dysfunctional attachment disorders and traumatic experiences show [16,17]. Sometimes, it takes a long time in the scientific world to make changes happen.
Carl Gustav Jung and Melanie Klein: Private life and scientific commitment
Retracing the history of scientific psychology from its origins, in his “Psychological Types” Jung states that each meta-psychological model is somehow the expression of its own creator’s psychology (1921). It is similar to saying that scientific psychology is a process that originates from psychological (and psychopathological) experiences of the fathers first and then of the sons, and that only with time, sometimes after generations, it can be freed of its own karma and start existing as an independent principle thanks to the contribution of the entire scientific community it belongs to. We will now try to reconsider this idea of Jung and to evaluate how the understanding of psychoses has taken a great variety of turns starting from different subjective experiences.
In her (unfinished) autobiography, Melanie Klein focuses multiple times on the relationship with her mother, writing that she does not feel any ambivalence towards her and providing, as a whole, a positive and emotionally appropriate image. However, things seem to have been much more complicated than that. In Grosskurt’s opinion, Klein stopped writing her work because she realized how she was transforming the mother into a reassuring idol, beyond the reality of facts . Roberto Speziale Bagliacca goes beyond that, to the point of affirming that her work had been interrupted because, inside Melanie Klein, “the unconscious need to protect the mother from any open critics had taken over, perhaps for fear that such critics might have destroyed her, as she often says about her patients” . The analysis of the Italian author shows how Klein had a deeply disturbed relationship with her mother. The latter seemed to have a behavior that Neumann would define uroboric (1949), meaning that she used to deeply discourage the psychological development of the daughter and to harshly deny her in her growth and emancipation attempts. It seems that, whenever Klein was feeling good, the mother was inaccessible, distant, to then mercifully reappear during her daughter’s severe moments of psychic suffering. As it is well known, the Austrian psychoanalyst had to undergo multiple psychiatric hospitalizations due to severe depressive episodes . During those hospitalizations, it seems that Klein’s mother changed her behavior to the point of becoming deeply loving and caring. The maternal love could only reach the daughter under extremely painful circumstances or in sickness. However, it seems that the mother would disengage again as soon as Melanie recovered. Calling on Watzlawick again, we can only imagine what form of paradoxical communication Klein been subjected to throughout all her life: she, a great psychoanalyst, and daughter of a mother who only recognized her when she was ill. It looks like Klein did not have a way out: She could either live the pain of her mother’s absence in health, or feel her love provided she was ill. In conclusion, from the analyses of Grosskurt and Speziale Bagliacca it appears that, throughout all her life, Klein has never really been able to understand the malfunctioning of the relationship with her mother and that she has never questioned her as a disturbed and disturbing figure. A dissociative modality which has kept at a distance the contradictory aspects of the maternal figure. Perhaps it is true that Klein was not capable of putting together the pieces of her controversial relation with the mother. However, it is starting from this painful subjective experience that she has created the concepts of jealousy and envy, of schizo-paranoid and depressive conditions, concluding in an exceptionally skillful way that in a child, only the combination of positive and negative aspects of the object can lead to psychic balance, and if instead these two aspects were to be split, then psychopathology would sooner or later make its appearance. It is important to highlight how, in Klein’s view, psychosis ought to be considered as the failure of the Self in the combination of the principles of love and hatred (destructiveness). Hatred, acting on the unconscious, would be subject to a strengthening process resulting in the affirmation of the schizoparanoidal position, of which psychosis would simply be its behavioral manifestation . Klein does not seem to have considered the possibility that the failure of the integration process of the split objects could be influenced by the psychic functioning of the mother. In our opinion instead, if the mother were to be subject herself to severe forms of splitting, problems could only increase in the second generation.
Wilfred Bion’s thoughts align with Klein’s (1959), as much as to be considered her theoretical heir: in both authors, the child’s psychic development mainly depends on the quality of the unconscious affective relation with the mother. In Klein’s opinion, the child is the one who “acts” the projective identification on the mother, just alike Bion who says that the child projects the anxious beta elements on the unconscious of the mother in order for her to transform them into alpha elements. Therefore, if for Klein the mother does not have any particular responsibilities for her child’s psychopathological onset, for Bion the transformation of beta elements in alpha depends on some maternal skills that were never really doubted; but is every mother capable of playing the alpha function? In particular, Hinshelwood underlines how “the mother has to be in a state of calm receptiveness in order to absorb the feelings of the child and give them a meaning. Through projective identification, the child instills into his mother’s mind a state of anxiety and fear, perceived as incomprehensible and intolerable (1989)” . Nowadays, it is very hard to imagine that this condition of calm receptiveness could definitely be at the fingertips of most contemporary women. It would seem far more likely that, provided each child project in the mother their anxious states, such psychic process could trigger anxious counter reactions, causing deep insecurity and inquietude conditions in the child. If it is true that each child is to project anxiety and fear on the mother, it is not unlikely that such feelings will push at a door that has already been open for a long time.
About psychoses, the most relevant meeting point between Klein and Bion is that they both created a pathogenesis model which collocates in the early stages of psychic development the most interesting time period of the future onset of psychotic psychopathology. From our perspective, the boundary of their thoughts is the inability to recognize that some disturbing relational aspects could have had a leading role in the structurization of psychotic functioning and that Klein’s personal experience would represent its main clue. Klein seems to have been exhaustive in relation to the analytical treatment of schizophrenic patients (1955) and she highlighted how the failure of the split objects integration and the affirmation of projective identification is the main responsible for schizophrenic disorder. Bion, in his analytical work with schizophrenic patients, in addition to the hypotheses of Klein states that in psychotic personalities there is a constitutional element (genetically determined, as we would call it today) that actually makes the psychotic patient different from any other patients. Bion concludes by saying that, with a psychotic patient the best achievable result “will uniquely consist in the self-awareness of the psychic reality: He will realize to be affected by delusions and misperception the therapist should not allow, not even for a second, that the patient loses his focus from the awareness of being ill or from the hatred towards he who, after many years, has finally succeeded in leading him to an emotional contact with those facts he has been trying to escape throughout his entire existence (1967)”. Considering the journey at the basis of our work, and although we are aware of the greatest difficulties in the treatment of psychoses, we do not feel like sharing Bion’s conceptual conclusions, for whom it seems that the only achievable result is the selfacceptance of being crazy.
Furthermore Bion’s therapeutic approach is, at some points, characterized by some interpretations of the available material which are excessively dogmatically adherent to Freud’s sexuality theory. An approach that does not seem to have impacted the evolution of psychotherapeutic treatment with psychotic patients.
We can end our consideration by highlighting how Klein’s thought had the credit of placing in early development stages all the premises for the future psychotic onset, although it was not able, from our point of view, to comprehend its relational meaning nor to test an appropriate therapeutic solution to this purpose.
In the introduction to Jung’s Red Book, Shamdasani, reporting various fragments from different sources, including some letters written by the father of analytical psychology, underlines how the start of Jung’s work, published posthumously, was characterized by a period of deep inner crisis, so much that Jung himself thought it could have turned out into a psychotic episode . In particular, the rupture with Freud was one of the most meaningful events for Jung at that time. This circumstance has been interpreted multiple times analytically and probably with a good reason, such as the expression of the existence of a paternal complex in Jung.
In this regard, Hogenson highlighted how the interpretative debate on the case of president about the concept of libido, represented one of the main aspects of the break up between Jung and Freud: It was not limited to psycho-analytical interpretation but it also represented a battle for the freedom and the affirmation of one’s thought . However, Hogenson adds something more, something that opens the doors to our view: In the American author’s opinion, the Red Book has represented for Jung “the introvert’s need to build a system that can contain the experiences of the unconscious”. It was probably that second personality, a few centuries older than Jung himself, to write the red book; that same personality that Jung, has he said in the red book, admits to have been inhabited . That same autonomous personality who built the Bollinger tower and often lived there in solitude. At this point, the best clinicians would dispose of enough material to launch themselves into the most varied diagnoses, but we are interested to underline another aspect here, the one brought to light by Perry: The psychotic condition, or even, the split dimension manifested through psychosis, is an aspect of the psyche with which it is possible to coexist and which has its own psychological meaning. And there is more: If not repressed, it is a dimension able to generate deeply rich contents, both on an individual and on a collective level. The red book is certainly a visionary and a self-therapeutic work at the same time. We believe there is an aspect mentioned many times by Jung in the red book: For him, that period of time was his greatest sacrifice not to surrender to the Ego omnipotence’s temptation and to stay as much as possible close to the experience of the Self. With the separation from Freud, who had pointed at him as his dolphin, Jung gave up on the idea of becoming an extremely powerful man, a condition that would anyway have probably sacrificed his deepest and most free thought expression.
As we have been trying to demonstrate, both Jung and Klein have been inhabited by affection complexes that have been well present in some periods of their lives and that caused deep suffering in both of them. The first of them tried to find a way to stay in contact with his own demons, whereas the latter failed in the same attempt.
At a later time John Bowlby, differently from Klein, who had also analyzed him, had the courage to deeply call into question the psychic functioning of the mother: Bowlby with his attachment theory, determined the greatest revolution in the world of the psychoanalysis of object relations and of all the dynamic psychology of the last forty years [26-28]. In some ways the relation between Klein and Bowlby resembles the one between Freud and Jung: both relationships have been characterized by a deep rift, made necessary so that the youngest could express their own thoughts freely.
At this point, by putting together Perry’s ideas on pre-psychotic personalities and Bowlby’s thought on individuals with insecure attachment issues, now a days we can add something to what has been said in the past: Periodically, no longer able to sustain as a total truth what was in reality only a partial truth, the conscious psychic system shatters, in the need to make room to new pieces of truth that at that point needed to become constituent elements of the complex puzzle of consciousness. The loving aspect of primary relations needs to be put together with its dark side, but this is something extremely hard to achieve alone, without any help. Even Jung expressed himself on the dark side of the mother archetype, a concept later on well explored by Neumann in his works [29-32]. After all, Jung and Neumann’s perspectives have anticipated by decades Bowlby’s argumentation on insecure attachment forms. The greatest merit of the attachment theory was the scientific demonstration that disturbed caregivers strictly relate with disturbed affective relations, which is in fact a clean break in comparison to the previous orthodox psychoanalytical views.
What is therefore being repressed inside the unconscious of a patient who will present acute psychosis? What is repressed is the dark side of his surrounding reality, the shadow side of his reference figures, of his belonging group, and of the world he lives in: Very often, within psychotic breaks we can find social and cultural themes which refer to the collective unconscious, but this is not the right seat to face this subject. Anyone who has had experiences with psychotic breaks knows well how, in the acute phase, controlled by a feeling of extremely deep anger, patients often pounce on their relatives, accusing them of being despicable people and to be the reason behind their discomforts. Of course, the patient is delirious, but why is he being delirious saying certain things instead of others? In psychotic patients’ families, it is extremely frequent to find entangled relations, who are against children’s emancipation, especially in the matriarchal societies of the Southern world . It is not infrequent that psycho-education and families’ involvement during care processes have to face power and psychological submission dynamics which damage the psychotic patient.
Therefore, Perry believes that the conscious psyche, over the course of development, builds by necessity and by nature a system of meanings aimed at giving the individual a cohesive vision of himself, of his own relational system and of the world in general. If such weltanshauung is sufficiently authentic, reliable and satisfying, then the psyche can evolve and progress. If instead, over time consciousness has only fed on partial truths while other parts have remained trapped in the unconscious (dissociation), then psychic evolution stops, and the fact that the system de-structures (psychosis) in the attempt to reach a new systematic organization could almost become desirable, a huge psycho-evolutionary opportunity, and the problem does not lie any longer in the psychotic condition itself but instead it is treated medically. Perry has unequivocally described the context of care for psychotic onset: The patient should be taken to a welcoming place, not medicalizing, preferably in a suburban context, with well trained staff able to give dignity to the ongoing psychotic episode. The patient should be free to decide whether he wants to be with others or alone, he should have a reference therapist, he should be able to express himself through symbolic activities such as drawing or sand play therapy. Generally speaking, it should be a recovery condition , able to respect the natural timings of the psychotic process which, in order to succeed, requires an avant-garde rehabilitative-psychiatric approach and ad hoc places of care. After all, with or without medications, we know that the acute phase of the disorder ends within a few weeks and this has always been highly considered by Perry, who pointed out how the prognosis could be completely different if the psychotic process was treated with respect, kindness and consideration, the same treatment concept expressed by Jakko Seikkula with the Open Dialogue approach . Perry, who was a psychiatrist, did not use any medications for the treatment of acute psychoses except for some very rare cases. He trusted the ability of the psyche to reorganize itself and [36- 39], just like Jung, he was interested in listening to his patients’ delusional stories, in the belief that within those surreal stories there was the sense to what was happening. If instead we counter pose all this with compulsory medical treatments, neuroleptic therapies aimed at turning psychotic symptoms off in the shortest possible time, sometimes causing mortifying clinical conditions both for patients and hosting facilities, then we cannot act surprised if patients are no longer willing to tell us about their psychotic experiences, to talk again about their days of madness. We cannot be upset if today psychiatric wards are still considered by most people as contemporary transpositions of old asylums. After all, forced hospitalizations often result into traumatizing experiences, and as such they move towards the mechanism of dissociation. Paradoxically, that could even be the way of treating and feeding the dissociative functioning. As per today, we do not dispose of any certainties on what might happen if the psychotic episode were to be lived as an experience of consciousness alteration treated with respect. Perry asked to wait from two to three months, period during which the psyche tries to reorganize. But in those moments, the psyche needs to be helped, so the presence of someone who knows what is going on is crucial, someone who can calmly assist the process and who will not be frightened by screams or anger manifestations, however intense they might be. Perry saw delusions and misperceptions as manifestations of an aimed process, which in the most fortunate cases would have resulted in a self-reorganization.
In 1974, Perry wrote about people who had come out after psychotic experiences as better humans. It is now important to dwell, even if briefly, on the problem of chronicization: From our perspective, psychosis becomes chronic if the psychological problems manifested through it are not faced or at least addressed. In some way, the psychotic patient remains stuck on a psychic problem from which he cannot move on, he “gets stuck” on a point of view that lasts unvaried over time. Jung affirms that hospitalized schizophrenic patients live a timeless reality, crystallized inside narrations and images that repeat themselves endlessly . Therefore, chronicization might depend on the block of the psychic reorganization process; despite longer or shorter remission periods, as soon as psychosis manifests itself again, the psychological problems of that moment are the same as those of the previous acute episode. In this view, psychotic crisis might be considered as spontaneous psychic manifestations through which internal suffering manifests itself [40-43]. According to Perry, it is very likely that what blocks the process largely depends both on how psychoses are treated, so on the use of pharmacotherapy for symptomatic remission, and on the system of values within which psychosis manifests itself, a context that sees in psychotic manifestations only an unintelligible and stigmatizing form of disease.
The considerations about Jung and Klein expressed in the previous pages enable us to come to the following conclusions: They both had to personally confront themselves with great psychic suffering, but if Klein did not seem to have had the possibility to come to the integration of the partial objects of her own primary affective experiences, Jung tried at all costs to get in contact with his own dark side, to dialogue with it, in the search for the integration of the psychic experience. We can assert that Klein, whose ego structure remained more intact, has manifested over the course of her life some depressive psychopathological episodes which could be related to traumatising primary (and persisting) affective experiences. It is very likely that the Austrian author found in the dissociation a protection of the suffering affective-relational dimension. On the contrary, Jung tried at all costs to get in contact with his own dissociated world, with his own demons, confident that confrontation would have enabled him to come to a more integrated personality. Although the Swiss author went through a phase of partial fragmentation of the ego structure (which he has probably maintained over time), in the end facts seem to have proved him right. On the theoretical-conceptual level Klein's thought created a model in which there is a clear division between healthy and sick, whereas Jung’s journey led to the overcoming of dichotomies, towards the Self archetype.
There is a very interesting connection between psychosis and dissociation: In our experience the dissociated psychic contents are often similar in psychosis and in dissociative disorders, for example the sense of omnipotence and manipulativeness. The difference lies in the solidity of the Ego. In acute psychosis, the cognitive system (Ego) is destroyed and all contents come out without filters (but through a symbolic language), so the psychotherapeutic work of reorganization starts without any help from the Ego. Instead, in dissociative conditions the control of the Ego is always present, and the reintegration work takes place under the control of the Ego (and this is not always a good thing). As it was widely demonstrated by van der Kolk, dissociation is that characteristic of the human nervous system which, in order to survive, enables to eliminate particularly painful experiences from consciousness. In our view, there are experiences which are just as painful but also ambiguous and unintelligible. They are not clearly traumatizing and removed experiences, but rather extended exposures to discordant experiences that structure consciousness in an inharmonic manner, just like in the case of a caregiver who, while smiling lovingly, feels inside a deep sense of anger and disdain. These are the most influencing experiences that we have encountered in the deep psychological world of psychotic patients. Such perspective highlights the theoretical-experimental limitations of Mirror Neurons: there is a substantial difference between being exposed in experimental situations to an affable smiling face and being exposed to faces that have been trying to make an effort for years to express positive feelings while pervaded by diametrically opposed feelings inside. As Perry suggested in the past and as Moskowitz has more recently clarified, there are very relevant meeting points between pre-psychotic and dissociative personalities. However, there is a substantial difference between the two authors: according to Moskowitz “schizophrenic syndromes represent…an ego-fragmentation that in extreme forms could be considered as an annihilation of the ego-self”; whereas according to Perry psychosis (or acute schizophrenia) is an activation of the psychic system aimed at overcoming the deep dissociative condition. Even Kalsched, a Jungian as well, theorized that the traumatized psyche carries a “selfhealing system” which is, potentially, able to kill or to preserve a patient’s psychic life. It all depends on how the issue is faced. The prognosis depends on the humanization of treatments. Our goal for the future is to try and demonstrate, following the contemporary scientific approach, the validity of the concept “natural reorganization of the psychic system.”
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Citation: Marchese, Fulvio. " Psychosis and Dissociation in the Psychodynamic Evolution”. Clin Schizophr Relat Psychoses 15: 4 (2021). Doi: 10.3371/CSRP.MF.290621
Copyright: © 2021 Marchese F. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.