Loss of Self in Psychosis

LOSS OF SELF IN PSYCHOSIS

In Loss of Self in Psychosis: Psychological Theory and Practice Simon Jakes takes a critical look at contemporary approaches to the psychology of psychosis. In doing so, he explores how these vastly different approaches, as well as our numerous conceptual- isations of schizophrenia, work to reduce the effectiveness of CBT as a treatment. Four different psychological approaches to psychosis are examined in the ﬁrst part of this book, as well as the development of CBT for psychosis and the theory behind this. In the second part, he describes the therapy of some clients and suggests that incorporating ideas from some of the different theories of psychosis in the same treatment may be beneﬁcial. Using extended examples from clinical practice over the past 20 years to illuminate his theories, Loss of Self in Psychosis: Psychological Theory and Practice will prove to be thought-provoking reading for clinical psychologists, psychiatrists and other mental health professionals working with this client group.

Simon Jakes is a clinical psychologist at the Bankstown Community Mental Health Team in South Western Sydney, New South Wales. He is also in private practice.

LOSS OF SELF IN PSYCHOSIS

Psychological Theory and Practice

Simon Jakes First published 2018 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2018 Simon Jakes The right of Simon Jakes to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Names: Jakes, Simon, 1956- author. Title: Loss of self in psychosis : psychological theory and practice / Simon Jakes. Description: Milton Park, Abingdon, Oxon ; New York, NY : Routledge, 2018. | Includes bibliographical references. Identifiers: LCCN 2017056921| ISBN 9781138680128 (hbk) | ISBN 9781138680135 (pbk) | ISBN 9781351213622 (ebk) | ISBN 9781315523996 (epub) | ISBN 9781315524016 (master) | ISBN 9781315524009 (web) | ISBN 9781315523989 (mobipocket) Subjects: LCSH: Psychoses—Treatment. Classification: LCC RC512 .J28 2018 | DDC 616.89—dc23 LC record available at https://lccn.loc.gov/2017056921

ISBN: 978-1-138-68012-8 (hbk) ISBN: 978-1-138-68013-5 (pbk) ISBN: 978-1-315-52401-6 (ebk)

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CONTENTS

Preface ix Acknowledgements xi

PART ONE 1

1 Introduction 3

2 Cognitive-behavioural therapy for psychosis (CBTp) 7

3 Normalisation 25

4 Cognitive neuropsychology of “schizophrenia” 42

5 Philosophical psychology 55

6 Psychoanalysis 77

PART TWO 109

7 Applications 111

References 130 Index 135

PREFACE

In 1975 I went to work in Claybury Hospital in Woodford Green, Essex. At that time deinstitutionalisation was yet to become a government policy. I was assigned to work on a “back ward”. The people on the ward had been there for many years. The patients had been there for many years and the staff had been there for many years. The charge nurse on the ward was approaching retirement. The charge nurse used to lock the doors at the time that the shift started, so if one was a couple of minutes late one could not get on the ward. We wore white coats and served up the client’s food. We then sat around, as there was nothing to do. He and the other nurses would reminisce about the good old days prior to anti-psychotic medication when patients would have to be restrained by being forced back with unattached doors. The clients sat around with nothing to do either, chairs pushed against the walls, interacting with no one. One man used to put together skipping ropes, and then undo them and then reassemble them. This was a leftover from when there used to be an “industrial therapy unit” in which patients had been employed, and he was the most active in his rather pathetic attempts to keep busy. And I rather naively thought that there must be a real medical need for these people to be kept for years in the hospital. I should have looked into the history of the hospital. I knew that it had once been called “Claybury Lunatic Asylum”, but I thought that was just outdated language, rather than being nearer to the truth. Claybury was one of the London County Council commissioned asylums for pauper lunatics. And the “pauper” gives the function away. Prior to the asylums, pauper lunatics had been housed in the workhouse, and the function of the asylum continued rather the same: providing food and shelter at an economic rate for the taxpayer and deterring anyone who could maintain themselves from asking for poor relief. This was living history. What had once been the way that all paupers were treated was now reserved only for the mad. x Preface

This double-speak about care and control is endemic in psychiatry. Anyway this was the ﬁrst lesson I had in the care of people with psychosis. The asylums are largely gone (and a fair amount of care in the community has gone with them, at least if Sydney is anything to go by). The dual function of mental health services to treat and to control is, however, still there, and this practical and political issue still runs through the philosophy of treatment. Theories get put to practical purposes. The theory of mental illnesses can be used to help people or it can be used to keep people in institutions for years. You have to watch out for theory. ACKNOWLEDGEMENTS

I would like to thank John Rhodes, Hazel Nelson, Paul Chadwick, Dallas Rae, Renate Wagner and Dick Hallam, who all helped in various ways with the ideas in this book and are not responsible for any of the errors, and the clients who allowed their stories to be told. Without the editorial team at Routledge the book would never have been written, so thanks to Joanne Forshaw, Charlotte Taylor and Katie Hemmings, and to Sarah Sibley for her very helpful work in putting order into my slightly chaotic manuscript. I would additionally like to thank Springer-Verlag for permission to publish excerpts from Karl Jasper’s “General Psychopathology”. Also Soraya, Ben, Joseph, Sam and Luke, who contributed considerably to the delay in ﬁnishing the book. And, of course, my parents.

PART ONE

1 INTRODUCTION

Feyerabend (1963), the philosopher of science, wrote:

Schizophrenics very often hold beliefs which are rigid, all-pervasive, and unconnected with reality, as are the best dogmatic philosophies. Only such beliefs come to them naturally whereas a professor may sometimes spend his whole life in attempting to ﬁnd arguments which create a similar state of mind . . . Unanimity of opinion may be ﬁtting for a church, for the frightened victims of some (ancient or modern) myth, or for the weak and willing followers of some tyrant; variety of opinion is a feature necessary for objective knowledge . . . and . . . a humanitarian outlook.

He meant this as a comment on dogmatic scientific theories rather than on “schizophrenics”, although some contemporary authors would argue that the delusions of people with psychosis are essentially dogmatic philosophies. But Feyerabend’s comments are of relevance to us in another way. In an area such as psychosis, workers or clinicians in one field often operate without reference or knowledge of the models being used by workers in other fields. So the psychologist exploring an information-processing model of psychosis will sometimes know nothing of the models being used in therapy. Clinicians are often advised to formulate the clients’ problems and relate them to a particular theory. But if the theories cannot claim to be a comprehensive explanation, then this, I will suggest, is dogmatism rather that empiricism. Feyerabend suggested that there is no one scientific method and that scientists have broken all the supposed rules of method. And we should use whatever method works. Part of the goal of writing this book is to bring together disparate psychological accounts of psychosis for the practising or aspiring clinician, because, I will suggest, as we don’t have an explanation of psychosis or schizophrenia, that as empiricists we should draw from different theories when they are useful. 4 Part one

In this book I review some quite different approaches to the psychology of psychosis. Not only are the models quite varied, but the way of describing the problem is also varied, reflecting different points of view. So, for example, some talk of “schizophrenia”, whereas others talk of “psychosis”. This can make it difficult to know what we are talking about or whether we are talking about the same thing. So, for example, if we eschew the term “schizophrenia” as an unreliable and invalid term, possibly a fiction, certainly stigmatising, and possibly a conspiracy, we are left talking of “psychosis”, but the problem here is that this is a very wide term. Becoming psychotic in the midst of a deep depression may or may not be the same as becoming psychotic after a long gradual withdrawal from the world, or becoming psychotic in an emotional crisis. I have generally kept to the terms that the original authors used. If an author has suggested a theory of “schizophrenia” I have not tried to eliminate the term from their theory (for then I might end up suggesting that they implied something about all psychotic experiences that they didn’t). But by no means am I endorsing the term or implying that it is a valid term, and it doesn’t mean I don’t think it should be abolished. I have put it in quotation marks. My emphasis in the book is to review these models at a theoretical level, rather than looking at the evidence for the model. Evidence is important, of course, but it comes and it goes. I review four different psychological approaches to psychosis or “schizophrenia”, and then talk about how some of these ideas might be useful in carrying out therapy with clients with these problems. As no one knows the cause of “schizophrenia”, it is useful to keep an open mind as to how to understand it. I found Bollas’s suggestion that maybe no one will ever understand the cause of schizophrenia strangely liberating. In psychology and psychotherapy we often cling to a model to reduce our anxiety about our work. It is comforting to feel that we can follow some leader who we deceive ourselves into thinking has the answers we are looking for. However, if we accept that no one theory can explain “schizophrenia” this is bad empiricism. In the second chapter I discuss the theory involved in the cognitive-behavioural therapy for psychosis. I discuss the development of CBT for psychosis (CBTp) and the developing theory behind this. CBT has been a big improvement for psychotic clients, but I will argue that the theory behind the therapy has been largely drawn from CBT carried out with clients with depression or anxiety. I will emphasise that cognitive-behavioural therapy for psychosis has a number of different sub-types and that there are a range of models. I will suggest that the theories behind CBTp don’t really get to grips with the psychotic experience, partly due to noble attempts to normalise the situation of the person with psychosis. In the third chapter I describe normalisation as a model of psychosis and how normalisation has been used as a form of CBT. I will review some of the evidence for the dimensionality of psychosis, and how this is used as a therapy. This chapter really goes hand in hand with the first chapter. Cognitive therapy has often approached emotional disorders from the point of view of seeing them as linked to normal emotional processes. In the fourth chapter I discuss two cognitive neuropsychological information-processing theories Introduction 5 of “schizophrenia”. These are the theories of Chris Frith and Ralph Hoffman. A person could write several volumes on the different information-processing models of “schizophrenia”, but these two models seem to have generated long-term interest. In the fifth chapter I will discuss some of the approaches to psychosis from philosophical psychology. After suggesting that Karl Jaspers has been generally misrepresented in many contemporary accounts of psychosis, and that he has a lot to offer us in the understanding of the psychotic person, I will discuss some of the responses to Frith and Hoffman by philosophers. Some philosophers these days write like theoretical psychologists. There is a huge literature on philosophical/ theoretical psychological accounts of psychosis. I will discuss some of these ideas. I will review alternatives to the “theory of mind” as ways to understand our ability to identify and talk about states of mind of oneself and others. Donald Davidson has suggested that the old problem of other minds, how we could know what other people were thinking or believed, has been replaced by the problem of how we know what we believe or think without recourse to any evidence. I may say that my friend is a conservative and if you ask me why I can point out his expressed opinions and, more importantly, his actions, but I can know that I am a conservative without basing this on my previous behaviour or expressed opinions. In the sixth chapter I will review two psychodynamic views of “schizophrenia”, the existential- phenomenological theory of R.D Laing in “The Divided Self” and Christopher Bollas’s model in “When the Sun Bursts”. Psychoanalysis has a discourse all of its own and I will attempt to introduce some of the basic parts of the model before discussing these theories. One can be sceptical of the whole approach of analysis, but it is interesting to look at “schizophrenia” from this perspective, I will suggest, because it offers a comprehensively psychological model of the symptoms, and a model which sees these symptoms as actions rather than passive happenings. In the final chapter I will tentatively suggest some ways in which some of the dynamic ideas might inform CBT for psychosis. At various points I give some clinical examples from clients I have seen. Usually these are amalgamations of clients seen at different times and places, and so although they are not fiction, they are also not accounts of any particular people. In addition these cases have been disguised. In two cases (discussed in part two) they are based on two particular clients. As these are more detailed accounts, it seemed more informative if they were based on individual stories rather than being combinations of clients. These two clients gave consent for this material to be included in the book. I have disguised the identities of these clients in any case, and some material was taken out at the request of one client. I would like to thank them for allowing their stories to be included here. In part two I describe the therapy of some clients and suggest how incorporating ideas from some of the different theories in the same treatment can be helpful. A partially theoretical eclecticism. If theories are tools then some theories are probably better suited for some uses rather than others. It is informative to understand how cognitive neuropsychology might think of psychosis; for example, if one is trying to establish links between 6 Part one different experiences and the brain. However, for other purposes this theory might get in the way. If you are thinking of your client as a computer then this may be as mistaken a belief as if you were to believe that you were a computer (as Laing pointed out). As a clinical psychologist I am biased towards theories of psychosis that humanise rather than those that objectify, because I am involved in trying to engage with clients as people. It’s horses for courses and maybe that is why the idea that no one will ever know the truth might feel liberating. 2 COGNITIVE-BEHAVIOURAL THERAPY FOR PSYCHOSIS (CBTp)

In this chapter I will review the development of CBT for psychosis, mainly with regard to the development of the implicit theory of the person with psychosis that emerges. CBT for psychosis has largely been aimed at trying to develop something helpful from a psychological point of view and theories have been incorporated along the way. It can be seen as a technical development. And this is really quite productive. One question is whether the theories developed for the purpose of promoting an intervention give a good account of the phenomena. Cognitive-behavioural therapy for psychosis has been something of a victory for psychological therapies. Psychological therapy for people with psychosis was generally regarded as at best useless and quite possibly dangerous. There are always diverging opinions but this was the mainstream view in the 60s and 70s. A biochemical theory of “schizophrenia” was dominant. The discovery of anti-psychotic medication and the production of psychotic states by mescaline, LSD and ampheta- mine had strengthened the idea that “schizophrenia” was purely biological. However, if we ﬁnd a drug that produces an emotional effect (let’s say alcohol) we aren’t inclined to think that biochemistry is all there is to say about emotions. So the popularity of the model can’t simply be explained by that. Anyhow the dominance of the medical model of psychosis and in particular “schizophrenia” was an established fact in the 60s, 70s and 80s. McGlashan and colleagues (1982) conducted a study of the outcome of people treated with inpatient psychodynamic psychotherapy at Chestnut Lodge (a psychodynamically oriented hospital in the USA). Clients there were treated with intensive psychotherapy and with little emphasis on medication. He found little evidence that the therapy was helping. Recovery rates at follow-up were similar to people treated elsewhere without psychotherapy, and for clients with a diagnosis of “schizophrenia” the outcome was poor, and along the lines suggested by Kraepelin. This had a major impact on Chestnut Lodge, which began to medicate clients, but it had a major impact on the 8 Part one perception of the role of psychotherapy in “schizophrenia”. Laing experimented with psychotherapy in London. But generally the cure was medication. Today the use of CBT in people with psychosis is recommended by the NICE guidelines for everyone diagnosed with schizophrenia: at least 16 sessions on a one to one basis. How was this turnaround achieved? Of course psychoanalytic therapy was aiming to cure “schizophrenia”. The goals of cognitive-behavioural therapy for psychosis are far more limited, but this seems here to have been a dialectic. From being offered intensive depth psychotherapy the pendulum swung to no therapy. The psychosocial elements of treatment were rehabilitation programmes and psychological therapy aimed at altering the emotional atmosphere in the family. Few people thought talking therapy with the clients was worthwhile any more.

Delusions as normal beliefs One important influence was Maher’s idea (1984) that delusions could be rational explanations of abnormal experiences. Or a rational explanation of a sense of bewilderment or puzzlement. Maher argued that delusions might be normal beliefs arrived at as an attempt to explain odd or anomalous experiences. For example, a person might begin to hear voices and then try to explain these voices and the explanation would become the delusion. Or they might begin to have a sense of puzzlement and then begin to seek the explanation of that feeling. As an explanation it is perfectly rational. This was the view of Evelyn Waugh (1957) when writing a fictionalised account of his own psychosis in “The Ordeal of Gilbert Pinfold”. In this account the protagonist goes on a boat trip and, under the influence of barbiturates, develops a paranoid psychosis. He begins to hear voices when no one is there and then rationalises this as a radio broadcast by the BBC. He cannot see a radio so the transmitters are buried in the ceiling of the boat. At one point he is confronted by seeming contradictory evidence and for a moment he questions, terrified, whether he is mad, but then manages to find another explanation to avoid this conclusion. The radio is talking about him so he begins to feel that there is a conspiracy against him organised by the BBC. Waugh said that in reflecting on this experience of his own he felt that he never lost his rationality. This is the formation of delusion as a rational explanation of hearing voices. It is worth pointing out that the voices and other psychotic experiences go unexplained in Maher’s account. But then it is an hypothesis about delusions rather than psychosis or “schizophrenia”, and this was one of the reasons why it helped to promote therapy. In addition to voices or visions, the other possibility considered by Maher is that the person may have a sense that things are strange. This might be a sense of the uncanny or that things seem altered in some ineffable way so that the person wants to explain this oddness. This seems a bit like what the psychiatrists call “delusional mood”. It is not that the person hears a voice or sees a vision but more that they have a sense that something odd is going on. This experience is not based on the perception of some other anomaly but is primary. Cognitive-behavioural therapy for psychosis (CBTp) 9

One objection to this account of delusions is that it doesn’t explain the bizarreness of many delusions. Why does a person who hears voices when no one else is around, or who hears voices coming from inanimate objects or from thin air, not consider the hypothesis that they might be having hallucinations, for example, rather than that he is being communicated with by the aliens, or hearing the BBC through a radio secreted in the ceiling? Maher argues that delusions are no more bizarre than many of the beliefs in the general population, such as alien abduction or communication with spirits. Furthermore, once a delusion is established it is partly maintained by the normal processes of selective attention and confirmatory bias. Once the person has the delusion they look for evidence that fits with the belief and ignore evidence that contradicts the belief. A traditional criterion for a belief being a delusion is that it is not amenable to empirical refutation. Maher argued that this was open to investigation. And this opened the door to clinicians trying to modify delusions using cognitive techniques. Watts, Powell and Austen (1973) carried out a study in which they used a single case design to look at the effect of two interventions on delusions and feelings of guilt. In a small number of cases, using the subject as their own control they found that delusional conviction reduced when they reviewed the evidence for the belief. When they discussed the beliefs related to guilt, the degree of belief in the delusion increased. Following up on this study Chadwick and Lowe (1990) reported the results of a series of single case experiments, which investigated whether it is possible to indeed affect chronic delusional beliefs using techniques of cognitive therapy (looking at the evidence for and against the belief, for example). There were six subjects, all of whom had long-standing delusional beliefs and most had a diagnosis of “schizophrenia”. The experimental design treated each person as his or her own control. There was a baseline period followed by an attempt to modify the belief using techniques of rational challenging, and this phase was then followed by a third phase in which a behavioural experiment was set up to test the truth of the belief. The multiple baseline design also involved clients having different lengths of baseline to each other. So that the baseline of different clients acted as a control across clients. During the baseline phase clients were asked to rate their degree of conviction in their delusional belief, and their degree of anxiety about and preoccupation with the belief. During the baseline (of varying lengths) there was no change in the degree of belief in the person’s delusion. Participants rated their degree of belief as 100% on almost all occasions. A modification of Shapiro’s personal questionnaire was used to assess the dependant variables. Once rational challenging began, however, some participants immediately responded with a reduction in degree of belief. Other participants’ degree of belief changed after the beginning of the behavioural experiments to test the belief. Some clients’ beliefs did not change. Psychology occasionally produces papers with striking unexpected results (despite sometimes proving things that no one doubted in the first place). This was an unexpected result and was seminal in generating a lot of interest in carrying out 10 Part one

CBT with psychotic clients. As well as the possibility that delusions could be altered by a rational disputation method, another important result of this study was that clients responded differently to each other. Some clients did not change their degree of belief at all. It was a small number of clients but it might make one think that averaging across different people with the same diagnosis was not going to be without difficulties. This variability in single cases has been found by other authors (Sharp and colleagues, 1996; Jakes, Rhodes and Turner, 1999), and the general problem was pointed out in the 1930s (Freud, 1933/2003). A number of trials of CBT have been carried out. In general if CBT is compared with treatment as usual, CBT does better. If CBT is compared to a control psychological therapy (“befriending”, for example, in the SOCRATES trial (Lewis and colleagues, 2002)) it is more difficult to establish an advantage to CBT (Jones and colleagues, 2012). This has been complicated in a number of ways. Often the therapy has been very brief. Lowe and Chadwick’s paper reported therapy that was also very brief, but in clinical practice Chadwick would usually see clients for around six months, and Hazel Nelson, in her treatment manual for cognitive therapy for “schizophrenia”, suggests about a year of therapy for clients who will engage. It seems intuitively unlikely that clients with long-standing delusional beliefs will respond optimally in five weeks of therapy as carried out in the SOCRATES trial. At least if one cannot demonstrate a conclusive difference between counselling and CBT in psychosis in five weeks this should not be taken to justify inferences about the effectiveness of longer-term psychological therapy. The duration of therapy produces a qualitatively different therapy. Going and talking to a therapist for a year and for a month are not likely the same experience for anyone. All of which, of course, doesn’t mean that cognitive therapy over the longer term is effective. Only it hasn’t been put to the test. Another important finding of this study was the demonstration that clients with delusions could engage in a collaborative therapy such as cognitive therapy. Often people would assume that psychological therapies were not possible with psychosis because they lacked “insight”. So it turns out that this isn’t true. Here the development of CBT for psychosis has coincided with the growth of the recovery movement and the push to provide talking therapies to people who are, or have been, psychotic. Furthermore, Birchwood (2014b; Birchwood and Trower, 2006) has argued that the dependent variables in the CBT for psychosis trials have been measuring the wrong thing, treating CBT as a quasi-neuroleptic. What he means by this is that many of the measures are of the presence of psychotic symptoms such as hallucinations and delusions, as with the PANSS and even the PSYRATS. He suggests that the aim of CBT for psychosis should be to alter the person’s emotional response to their experiences rather than the presence of these experiences. This gets a little complicated. With auditory hallucinations it seems quite unlikely that a cognitive intervention would alter these experiences, although if Maher’s model is correct one might be able to alter the appraisal of the experience. On the PANSS the latter change will not reflect in the score, and even on the PSYRATS, which was designed for use in trials of cognitive therapy, a large part of the ratings is to do with the Cognitive-behavioural therapy for psychosis (CBTp) 11 presence of the symptoms, so Birchwood’s criticism here seems correct. The most obvious direct measure of the effect of a cognitive intervention should be to measure the cognitive appraisals of the symptoms, the emotional response and maybe the person’s relationship to their experiences in some way. However, with delusions this seems less clear. The cognitive intervention used by Lowe and Chadwick was, for example, an attempt to alter the degree of belief in the delusion, and if this is successful it would lead to the person no longer being deluded. Of course if this was partially successful the person might still rate as having a symptom, if the outcome is either the presence or absence of a symptom. In this situation the PSYRATS is more useful than the PANSS, as it allows for degrees of belief rather that the presence or absence (Haddock and colleagues, 1999).

Cognitive therapies for psychosis

Beginnings and basics There are a number of different sub-species of cognitive therapies for psychosis, and these also involve differences in the underlying model of psychosis. Chadwick, Birchwood and Trower’s (1996) model of cognitive therapy was important as one of the first manuals describing the application of CBT with people with “delusions, paranoia and voices”. When it was published, the idea that one could carry out this therapy with people with psychosis was controversial. Kingdon and Turkington’s (1994, 2005) work on normalisation in cognitive therapy with “schizophrenia” predated this book and takes a slightly different angle and will be discussed in the chapter on normalisation. Chadwick, Birchwood and Trower suggest analysing voices, delusions and paranoia using an A-B-C (Antecedent, Belief and Consequence) model drawn from Rational Emotive Therapy RET (Ellis). The delusion is a belief (B) about an event or series of events (A). It is this belief which causes emotional and behavioural consequences (C). The aim of a cognitive intervention is to reduce the negative emotional and behavioural consequences of the belief by changing the client’s beliefs about the antecedent event. This analysis is also used to analyse hallucinatory voices, where the voice is taken as the antecedent event, and the client’s beliefs about the voices mediate the emotional and behavioural consequences of the voices. This seemingly simple analysis has some interesting implications for therapy. First, the point of the therapy being to change the emotional consequences (as in traditional cognitive therapy for emotional disorders), the primary aim is not to alter the belief (the delusion); this is rather a means to an end. There are a number of technical differences from traditional CBT. They suggest a long period of engagement. During this time the therapist asks the client if they have any problems that they would like help with and gets a history of the problems and of the person’s personal history. They emphasise the centrality in cognitive therapy of a collaborative relationship. Not all attempts at cognitive therapy with this group of clients have had this emphasis, and there was a time when behaviour therapists advised intervening with this population by altering the 12 Part one environmental contingencies. When I was training as a clinical psychologist in 1981 I was seeing a client with hypochondriacal delusions and my supervisor suggested that when the client talked about his delusions I should look out of the window and when he talked about anything else I should engage him in conversation. This seemed to be a demonstration of the superficiality of a certain kind of behavioural approach. If this worked I wasn’t really sure how it was supposed to transfer to other relationships in his life. Stressing the collaborative nature of the relationship leads to the further consequences. First therapy has to focus on something the client wants to work on, not what other people think he or she should work on. A consultant psychiatrist I worked with suggested to a client that he should see me in order to work on his “delusions”. I remember the frown on the face of the client and the sinking feeling I had about how this might work out. If we are collaborating with the client then the goal has to be shared. There is an issue about not colluding with a client, and obviously it is unhelpful to suggest to the client that they are right about the delusion. Working with the problem that the client brings is obviously the best way to engage the client in therapy (Chadwick has developed this further in his later book (2006)). At some point after having engaged the client in therapy the therapist will want to discuss, collaboratively with the client, whether it might be useful to examine the possibility that there may be an alternative explanation for the evidence that they have for their delusion. At this point it is important to be able to explain to the client how they might benefit if the belief is false and to have an alternative explanation of the evidence for the delusion. If the client doesn’t see any negative consequences resulting from his or her belief then there isn’t a possibility of doing a cognitive therapy. If the client agrees that there would be benefits in exploring if the delusion is the correct explanation, then the therapy becomes a standard cognitive therapy using examining evidence, thinking of other alternative explanations and setting up experiments to test the belief (sometimes called behavioural experiments, although exactly why “behavioural” is a little obscure). Essentially it is arranging reality tests of the belief. Not much work is done on automatic thoughts, because the phenomenology of the problem is different to depression, in which it is often easy to establish that the client sees their thinking as unreasonable, the procedure is more like working on assumptions or core beliefs. Other approaches to cognitive-behavioural therapy for psychosis have concentrated on teaching particular skills such as enhancing strategies for dealing with verbal hallucinations, and this has become a quite sophisticated procedure, dealing with delusions using in-session role play, for example. Treatment trials for cognitive- behavioural therapy for psychosis have typically included a variety of different CBT techniques, such as coping strategies and self-esteem. Hazel Nelson (1997, 2005) developed a series of workshops teaching cognitive therapy for psychotic symptoms to mental health professionals, which developed from the work of Chadwick, Birchwood and Trower (1996). Again the emphasis is on delusion modification or modifying beliefs associated with hallucinations. She saw clients for long periods of time (and worked largely with clients who were inpatients with long-term symptoms, not relieved by medication). Her two books Cognitive-behavioural therapy for psychosis (CBTp) 13 on cognitive therapy are full of detailed suggestions on how to implement CBT. This is because the books are derived from teaching workshops and this makes them very helpful for learning and implementing the techniques. She adds several different components to the therapy which do develop Birchwood and colleagues’ initial presentation. Her books are very helpful to the beginning therapist, as they detail the progress through therapy step by step. She emphasises a long period of engagement with the client. One difference in method is that rather than putting to the client that there are different possible hypotheses about the client’s experiences, one being the client’s hypothesis and an alternative being that the client has come to a mistaken belief in some way and then asking if the client would be interested in examining this, she suggests floating the possible alternative belief in a tentative way, then moving off the subject to return to it later if the client rejects this possibility. She suggests that it is important to prepare for the delusion modification stage in a number of ways. First one needs to understand the evidence that the client holds for their belief; how the belief is rationalised by the client. Secondly she thinks it is important to be clear about the emotional reasons the client may have for holding the belief. So, for example, I may believe, as one of our clients did, that I am monitored by spy satellite which is controlled by my ill-intentioned father and that this has a wholly negative effect on me emotionally and behaviourally. I feel anxious all the time and I don’t believe that I can progress in my life because of all this monitoring, and I also feel persecuted and hatred towards my father for all this persecution. Nonetheless I may feel, as this client actually did feel, that if I discovered that I was wrong about this I would be worse off. This particular client felt that if he discovered that he had lived in this restricted manner for twenty years for no reason this would be unbearable and that his life would not be worth living. Actually, Nelson suggests that if you ask the person, at the appropriate time, for the advantages and disadvantages of the belief being true they will often tell you. This is usually true. But not always. I had a client who believed that she was the mother of a child in another part of the country and that this had been deliberately concealed from her, in a complicated way. When I asked her about the advantages and disadvantages of this being true or false, she said that it would be a good idea to investigate it; but her manner made it really clear that she didn’t really think this was a good idea at all. Basically she could not seriously entertain the possibility of being wrong. In this case it would have been helpful to explore the negative consequences, from her point of view, of discovering that she was not the mother. She had a serious battle with the mental health service about her diagnosis, so a lot of her self-esteem was tied up in not accepting that she had been psychotic, and I think that I had not really thought through how difficult it would be for her. She had fallen out with the rest of the team. She wanted to go on seeing me after disengaging from the team, and I think that this was because I didn’t insist on telling her that she was wrong about having been psychotic. So maybe there has to be some ability to think of a belief from the outside to think about the advantages and disadvantages of holding it in a realistic way. Or maybe it is necessary that the client’s emotional investment in the delusion being true has been addressed. I think 14 Part one that in this case I had not sufficiently addressed this latter factor. Another salutary example was a client who was in an inpatient unit in Sydney and who believed that she was related to all the doctors in the unit. She had held this belief for some time. Her key worker pointed out to her that in actuality all her relatives lived abroad and that maybe she believed that she was related to the doctors as a compensation for having no relatives in the country. The client in this case did not, as is usually the case, just deny this; she accepted it as an interpretation of her behaviour, but that night escaped and ran away from the unit. This is fortunately a rare occurrence. Presumably she felt overwhelmed by this idea. Possibly this was a correct understanding of her delusion and one function of the delusion was to avoid recognising this sad fact about her life. One aim of the cognitive model is to encourage the client to view his or her beliefs as an interpretation of the world rather than the interpretation of the world. However, we don’t regard all our beliefs as open to question. If someone suggested to you that maybe you should investigate whether your name was really your name or whether you really lived on Earth and not Pluto, you might find it difficult to realistically think that this was worthy of investigation. The advantages to not believing that I am wrong about my name seem largely to be the advantages of not being psychotic. And of course this is often the pertinent issue. The discussion of the motives that a person has for holding his or her beliefs changes this cognitive model from a simple information-processing one. Maher’s account is that the beliefs are held in order to explain unusual experiences. To hold a belief because it is uncomfortable not to hold the belief is a different model. This suggests that some degree of self-deception is involved in the process. Of course this probably shouldn’t be that surprising, as self-deception is such a ubiquitous phenomenon in everyday life beliefs. Stuart Sutherland (1992) documents many of these, and of course the work on cognitive dissonance is all about this issue, but of course self-deception, particular of the self-serving kind, really is the subject of our everyday experience. An information-processing model of belief can make it look as if self-deception must involve some kind of contradiction. How can I deceive myself about, for example, my motives in getting angry about an issue with my partner? That we all know we can do this seems to imply some kind of dissociation or “splitting” as part of the normal functioning of the mind. This raises the question of the degree of self-deception involved in delusion and psychosis in other ways. Another innovation in Nelson’s model is the idea of partial modification of a delusional belief. She suggests that for various reasons it may not be possible to alter the delusional belief and in these cases one can aim at a partial modification of the belief – that is, to modify the aspect of the belief which causes distress while leaving the basic belief unchanged. So, for example, in the case mentioned above of the client who believed that he was monitored by a spy satellite, if the client felt (as this client did) that there would be severe consequences if it transpired that he had been wrong, he thought that this would mean that his life was meaningless. So although it would be unhelpful to try to demonstrate that this was untrue, one Cognitive-behavioural therapy for psychosis (CBTp) 15 might try to change some aspect of the belief, such as whether the intention of the monitoring was malicious. Nelson also suggests that some delusions have what she calls a “deep meaning”, by which she means that they have a symbolic meaning relating, for example, to a trauma, as some dreams do. She suggests that this is not always the case. This again is a significant change to a simple information-processing model of psychotic symptoms, although, of course, not incompatible with this account. So, for example, in the case of the woman who was a patient in the hospital in Sydney and whose relatives all lived overseas, her belief that she was related to all the doctors on the ward can be thought of as a symbolic expression of the need to be connected to people and her grief that she is alone. If a client has a delusion that seems to symbolise an important conflict or unfilled need, the explanation cannot be simply that the person is making sense of the available evidence, of course. If someone believes that they are the King of Australia we can explain this as a result of odd experiences which lead to that belief. For example, a client I saw who did believe that he was the King of Australia believed this because he had been told so by hallucinatory voices, and references to this on the television. Once he believed this he found evidence for this is the way that people related to him, and the fact that he was detained in the hospital also was explained by his identity. However, as I got to know him it was also true that he had a sense of low self-esteem and the delusion did also lift his mood. There is a debate in the literature about whether persecutory delusions are a defence against low self-esteem or not which relates to this debate (Bentall, 2003). Additionally, there are a number of cognitive models which are multifactorial and in which delusions are fuelled by emotional disturbances, anxiety or depression. One problem here, I think, is these multifactorial accounts can become untestable, in the sense that it is hard to think of a case which could not be made to fit in with the data. However, with the King of Australia the delusion did symbolise a need that he had. He had a relationship with a number of women in which he had been rejected or found it hard to commit to. At one point he found himself telling his girlfriend that he did not want to be with her and then returning to his home only to feel that he wanted to be with her. Of course the voices weren’t really independent experiences leading to a conclusion; the voices were generated by him, so it is possible to tell this story in a reverse order. That is that the voices are an expression of his conflict. That is that he wanted to be important and significant to other people. Actually, neither the evidence nor the symbolised need fully explains the delusion, in that some other factor has led to these experiences being expressed in a delusion. He could have formed the belief that he was unlovable, or that he was choosing the wrong girlfriends and that his voices were hallucinatory. Hearing a voice telling you that you are the King of Australia is not really evidence that you are, in a purely logical sense. You can’t convince anyone else you are the King because a voice told you so. It is tempting but false to say in this circumstance that there is a biological explanation for this. What this really amounts to (so long 16 Part one as we cannot describe this process in detail) is saying that the jump is not comprehensible in the sense of not being justified by the evidence. Peter Strawson (1972) has argued that we can explain a person’s behaviour in two different ways. We can give an account of the person’s behaviour as a physical system or we can explain it in terms of their reasons, desires and purposes. So we could explain a person’s angry outburst in terms of their perception that they have been insulted, or we could talk about the activation of certain parts of their brain, the production of adrenaline and the effects this has on their body, etc. He suggests that we don’t move from an account in terms of reasons and motives to a physical account on the basis of having information about the physical processes but when we find that we can’t explain their behaviour in terms of their reasons. So if we adopt a biological account it really means we don’t think that we can understand the behaviour psychologically. Nelson mentions a client who had the delusion that she was contaminated with germs and who had a history of sexual abuse. In this case the delusion symbolises the trauma and the meaning of the trauma. In the previous case the delusion symbolises the need or the goal. For Nelson it is an important part of the therapy to describe in detail the beliefs the client has which support the delusion or prevent the delusion from being questioned. These include beliefs about the significance of having a mental illness, of having “schizophrenia” or of having been wrong about the delusional belief. It is important to understand these beliefs and address them before beginning to question the delusional belief itself. Other beliefs supporting a delusion are that if the delusion were false it would mean that the person was crazy or that it would be incomprehensible why they had been wrong or that they had wasted a large number of years on a meaningless endeavour. The model used to explain delusions in cognitive-behavioural therapy for psychosis has developed through practice as therapists have attempted to deal with the problems that come up in therapy.

Person-centred cognitive therapy for distressing psychosis Chadwick’s (2006) developments to cognitive-behavioural therapy for psychosis are important in a number of ways. He suggests what he calls radical collaboration with the client – that is, working with the client from the client’s perspective. In earlier versions the idea was to work from the client’s perspective with the aim of getting to our perspective. So after some sessions of listening to someone with a delusion talking about how they feel that they are in danger from their neighbours, we might suggest that we could investigate if this was true. With radical collaboration we don’t have this conversation as a pre-set goal for the therapy. He includes work on the person’s schemas using gestalt techniques, and this can be based on the person’s relationship to their voices or it can be derived from their emotional reactions to others or to themselves, as one might do with a non-psychotic client. Voices can embody someone’s schemas. A complication here is that the theory of early maladaptive schemas personifies aspects of a person’s mental life, in a way that Cognitive-behavioural therapy for psychosis (CBTp) 17 implies some basic splits in the personality. Young (2003) talks of schemas “struggling to survive” and the relationship of the schema to the rest of the personality involves a degree of dissociation. One technique that is used in schema work derives from gestalt therapy and involves talking to the client as if they were composed of a number of different personalities. The client is encouraged to put some part of his or her personality in a chair and to engage in a conversation with it, or to imagine a dialogue with oneself at a different age, or with someone who was important emotionally. This technique was originally used by Fritz Perls and colleagues (1951) as a way of healing splits in a personality. A person might carry on a dialogue with someone who they had a disagreement with, possibly a partner or a family member, and they would play both roles, moving between the chairs to speak the different parts of the dialogue. The aim of this technique was supposed to be to help the person integrate the split in them. So if the dialogue was with an imagined other person, the implicit idea was that the other person represented some aspect of the person’s relationship with themselves, i.e. that in conflictual relationships the other person is carrying some of our projections. When we ask a client to role play an interaction with an early maladaptive schema we are encouraging the person to think of themselves as in different parts. It implies a model in which the self is divided up. The dialogue with a schema wouldn’t make any sense if this was not the case. Schema therapy is an avowedly integrative therapy, so it is not just that the techniques derive from gestalt therapy, but that the implied psychological model is also integrative rather than cognitive, and this is a further complication for the theoretical basis of cognitive-behavioural therapy for psychosis. These are helpful suggestions about how to intervene with a client and how to help the client make sense of his or her experience. Chadwick argues that psychotic experiences are the result of stress and PTSD, and essentially one end of a continuum which extends into the general population. There is no essential difference between people who are experiencing a psychotic breakdown and those who are not. Hallucinations, voices and other psychotic experiences occur in the general population (Chapter 3). This, of course, is not an explanation of these experiences. There is a difference between two uses of the word “normal”. One use is that something happens frequently in the population. It is “normal” to hallucinate means that many people do (and indeed a fairly consistent finding is that about 10% of the population report having had an hallucinatory experience of a person (usually a visual experience but sometimes a voice)). The other use of “normal” implies correct or proper functioning as in having normal eyesight even if most people didn’t have normal eyesight. That a high proportion of people are short-sighted makes it normal in one sense but not in the other. With psychotic symptoms, how normal these are (in the sense of normal functioning) is going to be further complicated, as it depends also on the particular culture. That psychotic symptoms occur in the general population is interesting and important but obviously it isn’t an explanation of why or how these experiences occur. It may well be that no one has an answer to this of course, but it seems important that clients with severe 18 Part one psychosis live in a world which has little connection to the world as experienced by most people (I will return to this later).

Cognitive therapy for command hallucinations Birchwood’s group have further developed their practice of CBT. Byrne and colleagues (2006) (also Birchwood et al., 2004; Birchwood et al., 2014a) have elaborated an extension of cognitive-behavioural therapy for psychosis in “Cognitive Therapy for Command Hallucinations”. They point out that the beliefs of people who experience command hallucinations are of a particular type. In the earlier cognitive model of psychosis (Chadwick and colleagues, 1996) they stressed that the important factor was the interpretations or beliefs that the client held about their voices. In their further development of the cognitive model they address the question of why the client holds these particular beliefs. People with command hallucinations usually see their voices as powerful or omnipotent, and themselves as powerless and out of control (Birchwood and colleagues, 2004). Clients also personify the voices. The client experiences him- or herself in a personal relationship with a personified voice. They argue that this way of construing relationships may have a socio-biological basis, the ability or tendency to perceive social rank being an inherited biological capacity. The client then perceives the voice as a person and has a relationship with this person or entity. Furthermore, usually this relationship is one in which a particular dynamic plays out. That is a dominant/submissive relationship. Byrne and colleagues (2006) suggest that the client may have learnt this type of relationship in childhood from abusive experiences. This is similar to Jung’s idea of the collective unconscious, that there is an innate idea which can be triggered in particular situations. Certain ways of relating to people or expectations about people are part of our genetic make-up. They suggest that compliance with the voices in a range of ways (including symbolic appeasement of the voices) can be thought of as a safety behaviour, which inadvertently serves to avoid disconfirm- ation of the power of the voices. The therapy then targets the beliefs about the power of the voices and the amount of control the client has, the compliance with the voices (as a sort of behavioural experiment), the identity of the voices and the meaning of the experience (i.e. whether the client believes that he or she is experiencing the voices as a punishment for past wrongs or is being unjustly persecuted). But what is less clear is why the person personifies the voices and forms a relationship to them. I could have a dominance/subjugation schema and hear voices but not relate to the voices as people at all. I will return to this point in a later chapter. Jill, for example, heard command voices which told her to cut herself or jump in front of cars. She would cut her hands. She also had visual hallucinations of the voices. She saw hooded figures which would be in her living room or kitchen. These were disciples of the Devil and she was terrified that they would harm her. These figures blamed her for having been sexually abused as a child. The intention of the voices was to torment or kill her. She felt totally powerless; she thought that the voices and the person who had abused her were right to condemn Cognitive-behavioural therapy for psychosis (CBTp) 19 her and that she deserved to be punished. She did act on her command hallucinations as well as cutting herself, she had also jumped out in front of cars. She also felt hopeless about her life and her future and would contemplate killing herself. If she got admitted because of these thoughts it was very hard for the hospital to discharge her, as her feelings of suicidality were very chronic. It is tempting to suggest that her psychosis is a re-enactment of her early experiences, but why she re-enacts is not to be explained by personification. It is the personification that is really in need of explanation. The therapy involves challenging the beliefs around the power and controllabil- ity of the voices and the consequences of non-compliance, and encouraging the client to practise acting in a different way towards the voices. Although they do not mention it, one can imagine that this could involve asking clients to act out role plays with the voices (as Chadwick does, and also Tarrier (1992) in his coping enhancement therapy). In some ways this is a technical extension of the earlier work targeting the beliefs of the clients about voices. Beliefs are identified, albeit those particular themes are looked out for (power, control and powerlessness). However, the model now incorporates the relationship between the person and their voices. Much of the therapy is directed at changing the power balance in the relationship, not simply testing out the person’s beliefs about the voices. If Fred told his voices that he wasn’t going to do what they said this can be described as changing his beliefs about the voice. But it can also be described as beginning to change the nature of the relationship to the voices. Is this still a cognitive model of psychosis? Maybe this is a question that needs some clarification if we were to try to answer it. What is striking is the parallel between this way of thinking about the psychotic person’s experience and that of the psychoanalyst who takes the person to be disintegrating (discussed in the chapter on psychoanalysis). One can see the personification of voices as an example of a dissociation of different parts of the self. Cognitive therapy models of psychosis have mainly addressed paranoid delusions and voices, and have largely focussed on modifying beliefs, either delusional beliefs or beliefs about voices. (This is a slight oversimplification. Some manuals include work on self-esteem, for example). Paranoid beliefs are typically well organised and backed up by evidence and argument. Other delusions are not always the same as this. How these models can illuminate these other psychotic experiences is, however, less clear. In particular, passivity phenomenon, in which the person believes that thoughts are inserted into their mind or that their thoughts are broadcast or that another person controls their movements or their will. For example, a client of mine experienced a controlling force which prevented her from doing work around the house. This didn’t seem to be an interpretation of a voice but more a direct experience. The force was personified but was not a voice. Negative symptoms and the experience of loss of will also don’t seem particularly to be illuminated by a cognitive perspective. It is of course true that thought insertion involves the belief that someone else is putting thoughts in my mind, and this could be worked on by cognitive techniques, but it seems as if something has been missed here. 20 Part one

The person seems to be describing an experience, and one which is pretty much incomprehensible. What would be evidence that someone was putting thoughts into your mind? What does that even mean? There seems to be something about these beliefs which it is hard to explain using Maher’s hypothesis that delusions are rational explanations of unusual experiences. The focus on belief as the central problem seems to sidestep the problem. An atomistic view of the symptoms seems to miss the gestalt of the psychotic experience, particularly when the person has several different psychotic experiences.

Duration of therapy One important quality of any therapy is the duration. If the relationship is an important part of a psychological therapy as is usually found to be the case, then the duration of the therapy must be an important factor. Some of the cognitive therapies which have been developed have been of very brief durations. The NICE guidelines suggest that everyone that has a schizophrenic breakdown should be offered at least 16 planned sessions of CBT, but one of the major studies of CBT in psychosis, the SOCRATES trial (Lewis and colleagues, 2002), compared five weeks of CBT with a control therapy. Birchwood and colleagues, however, had suggested six months of therapy, and Nelson worked with people for over a year. Clearly there is a qualitative difference between seeing a therapist for five weeks and seeing a therapist every day for several years, whatever the supposed content of the sessions is. We don’t need a controlled trial to tell us that our relationships with others change over time and that you don’t need to be paranoid to find that you develop trust in a relationship over time. Five weeks is not going to be the same as a year.

Lysaker’s Metacognitive and Reflective Insight Therapy (MERIT) Metacognitive therapy has been developed for a variety of psychological disorders, but the expression has a number of different meanings. In anxiety and depression it has meant beliefs about beliefs and has often seemed to mean beliefs about emotions. For example, the belief that worry may drive you mad, or alternatively keep you safe, would be two examples of metacognitive beliefs (Wells, 2011). In personality disorder Fonagy and Bateman (2004) have developed an approach that they call mentalisation therapy. This is focus on the ability to understand the mental states of others and also of oneself. This is usually focussed on training clients to articulate the emotional state of other people and of themselves, usually in a situation in which there is some anxiety or conflict. Paul Lysaker (2017) has developed an integrative psychotherapy for people with “schizophrenia”, which he bases on the theory of metacognitive deficit/theory of mind deficit in “schizophrenia”. He calls the therapy Metacognitive and Reflective Insight Therapy (MERIT) (Dimaggio and colleagues, 2010; Dimaggio and Lysaker, 2015). Lysaker (2017) had developed a tool for assessing the level of metacognitive processing in people with “schizophrenia”. He uses a semi-structured interview to Cognitive-behavioural therapy for psychosis (CBTp) 21 rate the degree of metacognition in the thinking of the clients. He bases his ideas of metacognitive insight at the heart of his assessment interview not so much on the ideas of Frith but more on Bleuler. Bleuler’s (1950) idea is that the central characteristic or essence of schizophrenic psychosis is not the manifest “symptoms” (so loved of DSM and similar attempts to operationalise the definition of mental illness) but an underlying process which generates these symptoms. The underlying process being fragmentation or the splitting of the psychic functions. This is, of course, why he named it “schizophrenia”. Bleuler thought that the underlying cause of “schizophrenia” was an organic pathology. The nature of this biological disorder was unknown, but it manifested itself through certain psychological processes which in turn gave rise to the observed psychotic symptoms (delusions, hallucinations, cognitive impairments and social withdrawal). These underlying processes were a loosening of associations, weakness in affectivity and ambivalence. Bleuler had been influenced by Freud and in turn influenced Carl Jung. His terminology of “loosening of associations” was influenced by the psychology of the day, which thought of association of ideas as the fundamental way in which thinking worked (a tradition which can be traced to the British Empiricists, and which eventually became expressed in the idea of conditioning). Bleuler thought that association was the fundamental process of thought and related it to the physiology of the reflex arc. Bleuler’s concept of loosening of associations, then, is pointing to a more general difficulty in holding together coherent ideas. Splitting of the mind goes beyond the splitting of thought from feeling (which has been one interpretation of his theory). He thought that different complexes of ideas could be separated from each other, and this is similar in many ways to Janet’s concept of dissociation of parts of the personality. Certainly this is how this idea was developed by Jung (1935). The difference between Jung and Bleuler was that Bleuler thought that at bottom the schizophrenic process was an organic one. Thought was a matter of a breakdown in association, association was a matter of the linking together of neurons in the brain and hence the thinking disorder which was at the heart of “schizophrenia” was an organic weakness in the process of thought. Jung, however, thought that the fundamental process should be understood psychologically. Lysaker in thinking this process can be altered by a psychological intervention may be closer to Carl Jung than to Bleuler. Lysaker’s semi-structured interview, then, is based on the idea that in “schizophrenia” there is a disintegration of the personality through splitting and that one manifestation of this process of fragmentation is the lack of self-awareness or, if you will, metacognitive awareness. It assesses metacognition in a number of different areas. 1) Self-reflectivity – that is, awareness of one’s thoughts and actions, 2) awareness of others’ thoughts and actions as separate, 3) decentring – being aware that one is not always the centre of others’ thoughts or feelings, 4) mastery, by which he means being able to formulate a psychological problem and think about how it can be solved. There does seem to be some similarity to Frith’s ideas of metarepresentation (See Chapter 4). These metacognitive abilities are the targets of Lysaker’s therapy, and the scores on the tests are also the outcome measures of the approach. 22 Part one

The therapy is comprised of a number of different components. The therapy continues over a number of years. (Although De Jong and colleagues (2016) have published a pilot study which found changes in the MAS (albeit non-significant changes) over a period as short as 12 weeks.) They are carrying out a larger study which will be more likely to be able to detect significant changes in the treated group. Each session is comprised of the following components: the client’s goals, if he or she has goals, which are taken as central; the introduction of the therapist’s ideas into the conversation; asking for a narrative episode so as to elaborate on the understanding of the episode; framing some part of the client’s story as a psychological problem; and reflecting on interpersonal processes as they occur in the session. And reflecting on the process of the therapy both in the session and across time. One example (Hillis and colleagues, 2015) involved commenting to a client that the therapist wondered if the client talked about witches and angels in order to keep the therapist at a distance. This is given as an example of addressing the client’s agenda, but of course it is also an example of encouraging the client to think about their own state of mind or introducing their own ideas into the conversation. The idea is that all of these components should be addressed in each session. The aim of the therapy is to use the therapy session as a way of coaching the client in metacognitive skills. Some other approaches with a similar aim have taken a more academic-like approach, using artificial examples to teach these skills in a classroom- type way. Lysaker’s approach is more psychotherapeutic in nature. This raises the question of which of these approaches might be most appropriate, and this in turn goes back to how we view the metacognitive problems of the schizophrenic person. If one sees the problem as a purely information-processing problem then one might try to improve it by practice with artificial examples as had been attempted with working memory (albeit with possibly negative results in the latter case). If the problem is thought of as an interpersonal one then it makes sense to attempt this during a more psychotherapeutic context. In Lysaker’s therapy the examples of metacognition are all real-life examples, as they are taken either from the client’s life or personal reactions or from the therapy relationship or from the therapist’s observations. There seems to be the advantage of ecological validity in the psychotherapy situation, although of course one could argue that a group situation might have more apparent validity. Or even a combination of the both. Lysaker’s approach does seem to come close to the traditional model of psychodynamic therapy, although the aim is not to put the client in touch with unconscious feelings. During the two years or more of therapy the client and therapist are going to develop a more substantial relationship than if the client was being seen more briefly. This will make the discussions about the thoughts and feelings about the therapist or the therapy sessions more meaningful, but this may also be the only relationship that the client has, or the one with the most frequent contact. Actually, a similar issue arises with traditional cognitive therapy. If the important therapeutic ingredient is changing a negative thinking pattern, this could be accomplished by reading a book. Of course some optimistic psychologists have indeed suggested that Cognitive-behavioural therapy for psychosis (CBTp) 23 this is the way to provide therapy cheaply to large numbers of people and have developed computerised therapists. But it seems likely that a major part of the therapeutic effect of cognitive therapy is to do with the personal relationship to the therapist. With “schizophrenia”, one of the most striking symptoms or effects is the withdrawal from people and social isolation. It seems likely that an important part of MERIT (and indeed other therapies) is in the process of developing a relationship with another person. (This may explain why CBT for psychosis performs better than treatment as usual but that it is hard to show that it is better than control counselling conditions.) Is the use of the relationship here just a convenient example? Could the same effects be obtained by, say, discussing characters in books or films or acquaintances of the client? In a way this is the key difference between Lysaker’s model of therapy and that of the neurocognitive retrainers. The difference seems important. Is the client in need of a reparative relationship or information about how to read non-verbal cues?

Cognitive-behavioural therapy for psychosis: a therapy in search of a model? As I wrote at the beginning of this chapter, cognitive-behavioural therapy for psychosis has been a major achievement in returning psychological therapy to the treatment of psychosis. But our review of some of the various cognitive therapies for psychosis has not found a consistent explanation of psychosis. The cognitive model that has been applied to psychosis was developed originally by Albert Ellis, mainly in relation to emotional disorders, and then a similar model was developed by Aaron Beck in relation to depression and emotional disorders. Ellis wrote that the origins of this type of intervention lay in the ideas of the Stoics. We cannot control what happens to us in the world, but we can control our response to what happens to us, because this depends on what we say to ourselves. Here the essential idea is that distorted ways of thinking – illogical thinking or irrational, absolutist assumptions – are supposed to explain the disorder. My tendency to jump to negative conclusions about myself or about others is what produces my depressed mood. My irrational beliefs or overestimation of danger cause my anxiety disorder. However, the situation is very different with the cognitive model used with psychotic clients. The A-B-C model is an explanation of the distress that the client feels as a result of their psychotic experiences. For the A-B-C model, delusions and other interpretations of psychotic experiences cause distress. Delusions are accounts of other experiences. It is not an account of the psychotic experiences themselves. This model is compatible with a biological model of psychotic symptoms, whereas other authors have suggested that the psychotic experiences could be the result of trauma. Chadwick and colleagues (op. cit.) are informed by a dimensional view of psychosis. In many ways CBT for psychosis is also compatible with no theory of psychosis, as it is an attempt to help people to deal with the emotional consequences of psychosis. In a radio interview, Michael White, the narrative therapist, was asked his views on the possibility that “schizophrenia” might have a 24 Part one biological basis and he said that he didn’t think this would make any difference at all to his therapy. Cognitive therapy is a helpful therapeutic development and has drawn on models developed to explain other psychological symptoms to develop novel interventions. It is not, however, a psychological explanation of psychosis. However, this can lead to an implicit biological theory of psychosis. The theories of cognitive therapy can explain paranoid delusions and the emotional reaction to voices and stigma, but not the occurrence of voices or other psychotic experiences. Does this leave the explanation to the biologists, or worse the biological psychiatrists? 3 NORMALISATION

Hence it comes to pass that a man who is very sober, and of a right understanding in all things, may in one particular be as frantic as any in Bedlam; if either by any sudden very strong impression, or long ﬁxing his fancy upon one sort of thoughts, incoherent ideas have been cemented together so powerfully, as to remain united. But there are degrees of madness as of folly; the disorderly jumbling of ideas together is in some more and some less. (Locke, 1894)

In this chapter I will look at the idea that psychotic symptoms can be thought of as on a continuum with ordinary thinking rather than only occurring in qualitatively distinct states of mind or psychiatric illness. This has been important in the development of cognitive-behavioural therapy for psychosis as we have already seen. I will also describe how this model lends itself to normalisation as a psychological therapy (Kingdon and Turkington, 2005). This idea of a continuum is a theory about psychosis. Psychotic symptoms are part of the general experience of human- ity. Psychosis is a dimension not a category. And therefore not an illness. I will look at some of the evidence for this approach and give some ﬁrst-person accounts to bring the data to life, and then I will brieﬂy describe how it can be used as a therapy. Can a normalising account do justice to the data? Normalisation involves conceiving of symptoms as being on some type of continuum with ordinary experience. With anxiety disorders, a normalising approach is to see anxiety as the upper end of a continuum of fearful response. A non- normalising approach would be to see anxiety disorders as qualitatively different from normal anxiety. For example, in normal fear there is a physiological response and a behavioural response but also a particular situation (vis a dangerous situation). The dangerous situation rationalises the response. In anxiety disorders there is no objectively dangerous situation. To panic when in the presence of a lion is different 26 Part one to panicking when there is no objective danger, and to think in this way is to make a qualitative difference between anxiety disorders and normal fear. Normalising is to see the response as on a sliding scale of fearfulness. Psychotic symptoms have been thought to only occur in people who were “mentally ill”. Psychotic experiences do not just occur in “schizophrenia” or affective psychoses. They occur in the general population and in personality disorders (which psychiatrists do not classify as illness). These facts pose something of a problem for those who want to maintain that there is a qualitative distinction between psychotic illness and normal experience. Where do we draw the line?

Borderline personality disorder and brief psychotic experiences A number of studies have tried to distinguish the hallucinations and delusions which can occur in borderline personality disorder from those of psychotic disorders. Borderline personality disorder gets its name from the psychodynamic idea that it is a borderline psychotic state. This is not how it is seen in psychiatry in general, however. The underlying current assumptions in psychiatry are that psychotic disorders, and in particular “schizophrenia”, are brain disorders and that personality disorders are not brain disorders. The high levels of childhood trauma, fears of abandonment and emotional instability in people with borderline personality disorder would not ﬁt easily with the idea of it as a brain disorder (but see Read and colleagues (2004) for the incidence of childhood trauma in “schizophrenia”). The presence of hallucinations and delusions in borderline personality disorder is on this assumption evidence for the continuity theory of psychosis. And there is also a category of brief psychotic disorder in which clients have psychotic experiences for only a short period of time, such experiences not being caused by the use of drugs or alcohol. Psychiatry has tried to ﬁnd a way of distinguishing the hallucinations of these groups from those of the clients they want to describe as having a psychotic diagnosis. Schroeder and colleagues (2013) in a review of the prevalence of psychotic symptoms in clients with borderline personality disorder found that 20–50% report psychotic symptoms. Hallucinations can be similar to those in patients with psychotic disorders, in terms of phenomenology, emotional impact and their persistence over time. Consequently they suggest that terms like pseudo-psychotic or quasi-psychotic are misleading and should be avoided. Childhood trauma might play an important role in the development of psychotic symptoms in these patients. But, as they acknowledge, this may also be true of other disorders with psychosis. Gras (2014) also found about 30% of clients with borderline personality disorder had psychotic symptoms which were phenomenologically indistinguishable from those of people with “schizophrenia”. Slotema and colleagues (2012) in a meta-analysis of studies of the phenomenology of hallucinations found that there were no phenomenological factors that distinguished people diagnosed with “schizophrenia” from other people with other diagnoses. Normalisation 27

Psychiatrists have wanted to say that hallucinations and delusions in patients with borderline personality disorder are qualitatively distinct from those in patients with psychotic disorders, because if they are indistinguishable this raises questions about the cause of the symptoms. Why would we have such a different account of hallucinations in borderline and schizophrenic patients if they are indistinguishable? Logically, of course the psychotic symptoms could have different causes in the two cases. Or borderline psychotic symptoms could be explained biologically. They could be the result of trauma in the case of borderline patients and have a purely biological cause in the case of schizophrenic patients. But the supposed biological cause of schizophrenic symptoms is hardly a settled matter. And there is usually trauma in the early lives of schizophrenic patients too. The often transient nature of the symptoms, and the stress-related nature of the psychotic symptoms in borderline personality disorder, rather counts against an underlying synaptic disturbance as the cause. It is possible that the difference between borderline and “schizophrenic” diagnosis lies in the other symptoms and problems that they present with, not in the quality of the psychotic symptoms. The hallucinations get labelled “pseudo- hallucinations” because of the association with emotion dysregulation and self- harm. This raises the possibility that psychiatric diagnosis is not really done on the basis of the criteria of the DSM or ICD systems but rather on a more gestalt feeling about the patient. In any case, the presence of psychotic symptoms indistinguishable from those of “schizophrenia” in people who are not defined as ill is evidence for the continuity theory of psychosis. My client Tom is an example of this difficulty. Tom was a man of 35 who lived in Dartford in Essex and had been diagnosed as having an axis II disorder. He had a history of impulsivity, parasuicide and self-harm, and had problems with anger and chronic low self-esteem. He was an only child. A key event from his childhood was that his father developed chronic respiratory illness and had to give up work. He became depressed and became physically and emotionally abusive. Tom’s mother continued to work but was rarely home and was emotionally distant. Tom found it hard to fit in at school and behaved in ways that attracted a lot of negative attention. He behaved impulsively and self-harmed, and had fears of abandonment, which meant that he didn’t stay in relationships long enough to get rejected. He left school early and couldn’t stick to any job, being impulsive and changing his goals. He had anger problems. As an adult living with his parents, if he became angry he would smash up the house. In his thirties he began to have periods in which he would have paranoid ideas and have delusions of reference. At times these ideas went on for several weeks. His diagnosis was always changing and at one point he was given clozapine. This was withdrawn due to side effects. He went to an area of London where there was a large Muslim population and began to think that Muslim terrorists were going to kidnap him. This belief persisted for several days. During these brief episodes he would act on his delusional beliefs. He would sit in the garden on the ward to avoid being triggered by listening to the news. Any report of a crime would make him believe that he had committed the offence and he would get delusional memories of having 28 Part one been involved in the crime. He didn’t have any periods of hypomania, just psychosis and depression and the emotional difficulties mentioned above. And in a few weeks the psychosis would disappear. What should we say of the diagnosis here? And a checklist from the DSM is hardly helpful, as it is a purely stipulative definition. We can decide to call this a case of borderline personality disorder or “schizophrenia”, but a set of rules that allows us to agree on a label clearly doesn’t make the label valid. A DSM category that might apply would be acute and transient psychotic disorders. These are largely defined by time period. One way of thinking about the existence of transient psychotic disorders is that they evidence that psychosis is on a continuum. People have brief episodes of psychosis which are sometimes qualitatively indistinguishable from prolonged psychotic states. This type of presentation that does not fit neatly into the psychiatric classification is quite common (Ross, 2000). The fact that no one knew how to classify him and that he had brief psychotic periods in which he was truly acutely psychotic but that most of the time he presented with borderline symptoms can be seen as an example of psychosis being on a continuum. Ross has talked of “co-morbidity”. In this case psychotic symptoms are part of a general pattern of acute emotional distress.

Psychotic symptoms in the general population A surprisingly high number of people report experiencing voices or visions in the general population. Sidgwick and colleagues published the census of hallucinations in 1894. The aim of the census was to determine the base rate of hallucinations in the population so that it could be compared with hallucinations occurring before or after someone’s death, to determine if reports of hallucination could be explained by chance rather than by a supernatural cause. They interviewed 17,000 people in the UK and surveys were also conducted in France, Germany and the USA. There was a preponderance of visual hallucinations. They attempted to avoid bias in the selection of subjects by asking the collectors to ask the question of 25 people, to avoid the collectors choosing people who would respond “yes” to the questions. Actually, the main interest in the research group was to demonstrate a signiﬁcant association between hallucinations and recent deaths, so there should have been no inherent bias in the group to select false positive. Participants were asked the following question:

Have you ever, when completely awake, had a vivid impression of seeing or being touched by a living being or inanimate object or hearing a voice; which impression, so far as you could discover, was not due to any external physical cause?

Of the 17,000 participants 9.9% replied “yes”. Of course the sample wasn’t random. However, a variety of other surveys have found similar rates using a better sampling structure. About 10% of the population report experiences of hearing voices or seeing visions of people on a questionnaire Normalisation 29 measure. Posey and Losch (1983) used a questionnaire measure and surveyed 375 college students. 71% reported at least one hallucination (while wide awake), and 39% reported hearing their own voice spoken out loud while alone, and 39% reported hearing their thoughts spoken out loud. McKellar (1968) surveyed 500 people in the general population and found a reported rate of 25% for hallucinatory experiences. The numbers of people rated as hearing voices decreases if the assessment is made by psychiatric interview. The finding of hallucinations in the general population seems to support the idea of a continuum of psychotic experience. It can be argued that there are a number of problems with the methodology of these studies. The rates are lower if the study depends on interviewing the subject rather than using questionnaire data. However, although the rates are lower, the existence of hallucination in the general population is still found. Often people will only have had one or two hallucinations throughout their life, but this is not always the case. In an attempt to correct for these methodological problems, an important series of studies was conducted by Van Os and colleagues (Bak and colleagues, 2003). With questionnaire studies there is always a doubt about how the interviewee interpreted the question. I remember a client with “schizophrenia” reading out the Eysenck Personality Inventory as he completed it. He read out the Psychoticism item “Would you take drugs that might have strange or dangerous effects?” And then he thought out loud, “Well I take the psychiatric drugs and they have dangerous effects so I suppose the answer is ‘Yes’”. Not quite what the test designer had in mind and a possible source of spurious association! In order to avoid this sort of difficulty, Van Os and colleagues interviewed a large population sample. They interviewed 7,076 people drawn from the general population in the Netherlands. The sample was a stratified random sample. Individuals in Institutions were not eligible for inclusion in the study. They achieved a 64.2% response rate. Responders did not differ from the general population apart from having an underrepresent- ation of the 18–24 age group. They interviewed the subjects at home using trained non-clinicians using the Composite International Diagnostic Interview (CIDI). This interview was designed to identify psychotic and psychotic-like symptoms. The interviewers could rate participants’ reports of psychotic or psychotic-like experiences according to the following system: 1) no symptom, 2) symptom present but clinically not relevant (not bothered by it or seeking help for it), 3) symptom the result of taking drugs, 4) symptom the result of physical illness, 5) true psychiatric symptom, 6) symptom may be explained by real events (and hence may not be a symptom). If the participant reported a symptom rated by the interviewer as a true psychiatric symptom or a symptom explained by real events, the participant was re-assessed by a psychiatric registrar by telephone using the Structured Clinical Interview for Diagnosis (SCID). 3.3% of participants reported a true delusion, and 8.7% a non-clinically relevant delusion. 6.2% participants reported a true hallucination, and 1.7% a non-clinically relevant hallucination. This study is particularly interesting, as the classification is on the basis of interview. Most people who report delusions or hallucinations do not need help from psychiatric services. Furthermore 30 Part one there seems to be a continuum of experiences. Van Os has a category “non-clinical relevant hallucination” for people who are not bothered by or seeking care for their experiences. The incidence of hallucinations and delusions increases in people who have any kind of psychiatric diagnosis of some kind, i.e. including people with non-psychotic diagnoses. Strauss (1969) postulated a psychotic continuum on the basis of his experience using the present state examination. He found that some reports of patients seemed to lie between the categories of “present” and “absent”. He also tracked patients recovering from delusions and found that often a delusion belief would change into a non-delusional version of the belief. So that someone who, while acutely psychotic, was certain that they were being monitored by MI5 might end up just being unsure if they could trust the government. (A different dimension of psychosis, as it varies in the same person across time.) In later work Van Os and colleagues have examined in more detail these people with psychotic symptoms in the general population. A minority go on to develop psychiatric problems. If they do they may develop a range of problems, not just psychotic “illness”. People who were having a lot of these experiences were more likely to be seen as being in need of care. Whether they were rated as in need of care simply because of the frequency or severity of the psychotic experiences was not clear. However, that at interview 8.7% of the population are rated as having a delusion, and 6.2% are rated as having an hallucination (once one has excluded people who have these experiences in relation to taking drugs) is a striking finding, and tends to validate the high rates found in questionnaire studies. Furthermore the rates are higher in people with some diagnosis. This suggests rather strongly that the traditional idea of psychotic disorders as a separate category is not supported by the data, and that the endeavour to base psychiatry on classifying discrete illnesses is mistaken. The evidence fits better with the notion of an “Eigen psychosis” – that psychoses form one group. Of course a dimension of psychosis doesn’t mean that there are no important distinctions between people who occasionally have psychotic experiences and those who have these experiences continually. No doubt there is something of a labelling process, so that once someone is seen as disordered, possibly because they are not functioning socially or economically, we look for psychotic symptoms. But there is still the question why someone has frequent psychotic symptoms. And showing that something is common in the general population is obviously not an explanation of the experience. Johns and Van Os (2001) and Johns and colleagues (2014) also investigated people who have hallucinations in the general population. Most young people with these experiences will not go on to having psychiatric care, although a small group do. Whether delusions exist on a continuum is more difficult to assess in the general population, because it is unclear how bizarre a belief has to be to count as delusional, or semi-delusional. Delusions are beliefs which are impossible, incredible or false, and are held with a subjective certainty. But this is not enough for a belief to be a delusion. Criteria for the SCAN, for example, suggest that delusions should not fit with the culture, political views or religious group that the person belongs to. Furthermore, they suggest that delusions should not be understandable in terms of Normalisation 31 the particular development of the person. They give the example of a physicist who comes to believe that a certain idea is a solution to a particular problem he has been working on. (The need for these criteria could be seen as evidence for a continuum of bizarre beliefs. We need the criteria so that we don’t label everyone with different or obviously false beliefs psychotic.) Of course if one pushes this too far it may be just a matter of opinion if someone has a delusion or not. What counts as an understandable growth of an idea from a period of absorption in some eccentric theory may simply be another person’s evidence that the person is deluded. The example of the physicist from the SCAN suggests that the person has been absorbed in these ideas due to external reasons – e.g. work, but in other situations this decision will be very subjective. However, the general idea seems to be that a delusion is an idea which the person has developed idiosyncratically, rather than through social influence. Clearly this means that delusions cannot be assessed without finding out how the idea fits with the person’s social group and other interests. So questionnaires asking the respondent if they believe in a range of typical delusional ideas won’t be able to assess this. Nonetheless, it is still of interest to find out how common delusion-like ideas are in the general population, and Peters and colleagues (1999, 2004) have attempted to do this. She produced a questionnaire based on attenuated versions of various types of delusion. Items include questions about belief in telepathy, experiences of mind reading, thought echo and con- spiracies against the participant. A total of 444 healthy individuals completed the 21-item PDI. A sub-sample also filled out an in-depth schizotypal personality scale. Thirty-three deluded inpatients also completed the PDI. Individual items were endorsed by just over one in four healthy adults. Although the deluded sample scored significantly higher, the range of scores overlapped considerably, with 11% of healthy adults scoring higher than the mean of the deluded group. They did find differences, however, in the degree of conviction, preoccupation and distress between the deluded group and the control group. The Peters scale measures beliefs in telepathy, experiences of having thought broadcast or echo or thought insertion. Participants can, however, rate having these beliefs with a range of degree of belief. A Gallup poll conducted in the USA (2005) surveyed 1,002 adults over the age of 18. Gallup has a sophisticated sampling procedure, so it is likely that the sample reflects the population. They interview participants by phone. They asked inter- viewees if they believed, did not believe or were unsure about a range of paranormal phenomena. They found that 75% of Americans believed in some form of paranormal phenomenon. 41% believed in ESP, 37% believed in haunted houses, 31% telepathy, 26% clairvoyance, 25% astrology, 21% communication with the dead and 21% witches. These findings are in broad agreement with Peters’ findings in that a large proportion of the population believe in these ideas. Peters suggested that the degree of conviction, preoccupation and distress was higher in people who were deluded compared to the general population, and we don’t know this information about the Gallup sample. In clinical practice, delusions are quite often identified without attention to these more subtle criteria. If you are in an emergency department and tell the staff that 32 Part one you believe that you have received messages from God you are likely to be assessed as having a delusion. In a way, this is all rather question begging. If delusions are qualitatively different to other beliefs, then determining if they have arisen in an un-understandable way may be crucial. But of course that is the point at issue. If delusions and other psychotic symptoms are indeed on a continuum, then they may well be related to similar but attenuated versions of delusions. Psychiatric classification was developed by describing the experiences of people who were not functioning, and hallucinations are often prominent in people who have “schizophrenia”. The existence of people with similar experiences who were not unwell would not be evident to these psychiatrists – that is, psychiatrists have described the experience of a particular group of people but this is a selected sample, so they are not well placed to describe variants of normal experience (Jaynes, 1977). Oliver Sacks (2012) notes that hallucinations occur in creative people and not just in cases of mental sickness. The psychiatrist or clinical psychologist is in danger of concluding from a biased sample that hallucinations indicate sickness. A distinct possibility here is that not all voices are created equal. The voices heard by Freud when he was in danger and the continual voices of the chronically psychotic person are not necessarily part of the same phenomena. The gestalt may be important here. An important study was conducted by Romme and Escher (1989, 1993). One of Marius Romme’s chronically psychotic patients had found Julius Jaynes’ (1977) book “The Breakdown of the Bicameral Mind” helpful in coping with her auditory hallucinations. Jaynes had suggested that voice hearing had been common in antiquity and that internalising voices as an inner dialogue had been a consequence of cultural change. Previously the voice of conscience had been experienced externally as the voice of a God. He suggested that the experience of hearing voices used to be universal and was in any case still widespread in the general population. Romme and his patient appeared on TV, and after having explained how she coped with her voices they asked for people who heard voices to contact them. This resulted in a meeting in which they brought together people who contacted them. 450 people contacted them after the programme, from which they selected 20 people from this list who could cope with their voices and who had expressed themselves well to be speakers at a conference for voice hearers. Of the 450 who had contacted them 300 said that they could not cope with the voices and 150 said that they could. The conference was attended by 300 people. Speakers talked about their experience of adapting to the voices. Romme describes a typical pattern where the person begins by being frightened and confused by the experience and learns to accept and understand the voices. A significant number of the participants explained that their voices began during childhood. What is of interest for the present discussion is that a significant number of the participants experienced voices which occurred much of the time but which did not disturb or upset them. Romme suggests that those who heard voices which were negative about them or threatening Normalisation 33 were not accepted as part of the self, the voice sufferer, whereas those for whom the voices were positive and reassuring accepted the voices as part of their “internal self”. This is, of course, a suggestion of considerable interest for cognitive therapists, or others trying to carry out a psychological treatment with the client. If it is possible to be on better terms with the voices it may be possible to accept them as part of oneself. If one is able to accept the voices as part of oneself it may be possible to be on better terms with the voices. Many of the participants believed that the voices were real beings through whom they could communicate to others. For our purposes, the interesting thing is that many of these voice hearers had not been in touch with psychiatric services and were in no sense ill or disabled, unless one insists on the experience of voices as a sign of illness in itself. For 70% of the participants the voices had begun after a trauma, and 67% were unable to ignore the voices. Focussing only on the positive voices seemed to be a helpful strategy. Hallucinations and typical delusional ideas are reported in the general population. Some of the people who report these experiences will be in need of care as assessed by a team of psychologists and psychiatrists. However, most are not assessed as in need of care. Some will go on to develop “a disorder”, but for many people it will be a transient experience. However, in individual cases these unusual types of experience will be associated with creativity or health. Freud, for example, reported having twice been in danger of his life and during those periods hearing words as if somebody was shouting in his ear and seeing the words printed on pieces of paper in the air (Sacks, 2012).

Mystical experience and psychosis Psychiatrists see people who are in distress or who are distressing to other people. As a medical discipline it has tried to develop explanations for the problems that these people have in term of abnormal states of mind. However, by the nature of the people who consult psychiatrists, they don’t see people with unusual states of mind who are not causing a problem to anyone. One example is a mystical experience. I will give a number of examples, as these help to bring the experiences to life. The examples cover experiences that would be labelled as passivity experiences, hallucination or delusional mood in the psychiatric patient. There is a general principle that a belief doesn’t count as a delusion if it fits in with a socially sanctioned set of beliefs. This criterion may be meant to indicate a belief cannot be understood as learnt from others, because, after all, most of our beliefs are acquired socially, and most people can’t really justify many of their beliefs by evidence. However, this particular criterion can also be seen as making social conformity the criteria of sanity. In the Soviet Union psychiatry was involved in classifying political dissent as illness and confining dissidents in hospital, and in the past homosexuality and promiscuity have been classed as psychiatric illness. Why don’t we regard belief in God or the Devil or the feeling of being guided by a divine purpose, or remembering being abducted by aliens if you’re a member of the alien 34 Part one abduction society, as psychotic symptoms? This is presumably an admission that experiences which are indistinguishable from psychotic symptoms can occur in these settings in people who we don’t want to classify as ill, as they are in other respects functional. This seems to acknowledge that we sometimes can only tell if a symptom is psychotic by looking at the more general picture, and therefore that psychotic experiences per se occur in the general population. But what of people who found religions and who inspire others. Are we to classify the experiences that they have as psychotic? Examples are illuminating, as they convey the quality of the experience in a way that answers to questionnaires cannot. Joan of Arc heard voices and saw visions. She said that she had visions and messages from Saint Michael, Saint Catherine and Saint Margaret. On the basis of these visions she persuaded the king to allow her to help with the fight against the English. Although a peasant girl she was able to influence people. She obviously believed in her voices and visions as sources of inspiration, and held onto her belief in them at some risk to herself. Bernard Shaw (1946) in his introduction to “Saint Joan” suggests that Joan’s visions and voices are clearly not insanity but that some people experience inspiration through visions and voices and that this is just a different way of being sane. Given that she was clearly effective in her aims (i.e. inspiring the French armies against the English) it would seem odd to think of her voices as pathological. And the same would also go for Socrates and his daemon, his voice which gave him advice on what he should not do. In the not very distant past (and actually in the present too) some scientific investigators took seriously the idea of psychic or paranormal experiences and investigated them. Here it is interesting both that the people they investigated sometimes reported experiences which in another context would be thought to be psychotic but also that the investigators took seriously the idea of, for example, possession (an explanation which seems to take seriously the idea of two souls in one body). These hypotheses in the mouths of a client in an inpatient unit would be seen as examples of psychosis. Myers (1915) seems to give credence to experiences which would imply that one mind could include two consciousnesses. He writes that trance phenomenon

. . . cannot be intelligibly explained on any theory except that of possession. . . . control by a spirit of the sensitive’s organism and the temporary desertion of that organism by the percipients spirit . . . some secondary personality . . . going on gradually to complete control of all the supraliminal manifestations.

In regard to a case of automatic writing, Myers says:

At other times, especially when alone, he wrote automatically, retaining his own ordinary consciousness meanwhile and carrying on lengthy discussions with the “spirit inﬂuence” controlling his hand and answering his questions Normalisation 35

etc. . . . the handwriting of each spirit was the same as that which the same spirit was in the habit of employing in the automatic script. The claim of individuality was thus in all cases decisively made.

It seems here that the idea of alien control of actions is taken as a hypothesis to explain unusual occurrences by the investigator and, whether the idea is ultimately intelligible or not, it is taken as intelligible by Professor Myers. Indeed, such ideas are very common in our culture, the idea of the spirit leaving the body after death being quite commonplace. The idea of the ghost in the machine, as Gilbert Ryle characterised Descartes’ myth, may be a myth but it is part of a very common myth. It may be that we are deceived into thinking in this way by an underlying metaphor in our language. Nonetheless, it is not the province of psychosis alone to think in this way about our mental life. This is related to the idea of experiencing others’ thoughts in one’s own mind (a Schneiderian first rank symptom). Sheldrake (2013) has similarly investigated the “sense of being stared at”, and reports being able to demonstrate that people can detect when someone is looking at them from behind, via pre-cognition and telepathy. The point is not, of course, whether these investigators are right about these phenomena but rather that some experiences related to psychotic experiences are still well respected in some parts of the highly educated population. King James the First was not only convinced of the existence of witches but, somewhat terrifyingly, also thought that people who said that they didn’t believe in witches were often saying this because they were in league with the Devil. Newton wrote on the prophecies of Daniel and he read into the Biblical story such an intricate and complex series of symbolic meanings that one would be tempted to think of them as delusions of reference in a person presenting for help. A client of mine had a long-standing history of anxiety and PTSD. No one had ever thought that he had a psychotic illness. He was 65 and retired. He was happily married but found it difficult to maintain relationships outside his marriage. He was estranged from his family of origin. He wanted help with assertiveness. At one point he mentioned that he believed that people had occupied other planets and destroyed those planets using nuclear weapons prior to coming to Earth. He said that as Adam and Eve had seen God in the garden he must have had a material body and been a human being of sorts. He said that he hadn’t heard this from anyone else. If a person presented this belief in a different context it would undoubtably be thought of as delusional. It does not have the self-focus of most delusional beliefs but that it does not fit in with our general beliefs and that he cannot work out where it comes from would count in favour of this being thought of as a delusion. This particular person was interested in spiritualism and para-psychology but could not recall having read this idea or heard it elsewhere. There is an important social aspect of the process of describing experiences or beliefs as psychotic. If we look at how delusions are actually identified in practice we may get further in understating the concept than if we focus on trying to define the characteristics of subjective experience. Usually, when someone is classified as delusional it is because someone has made a complaint about the person. Usually, 36 Part one defining delusions is part of a practical process of dealing with people who are causing a nuisance to other people. In this context the threshold for calling a belief delusional goes down. It goes down further if someone has other symptoms. It may be that the symptom is called delusional rather that an overvalued idea because of the prior decision that someone is insane based on the person’s behaviour being problematic for other people. Calling the symptom a delusion may be part of a social process of dealing with people who do not conform in certain ways. Was my client delusional? It would be an odd thing to think that he was. And it may be that these types of beliefs are quite common, but not noticed. People also learn that it is a good idea not to talk about unusual experiences and beliefs for fear of being judged. Goffman (1961) carried out a year-long participant observation investigation of a psychiatric hospital. He got work as an assistant working in the physiotherapy department of an old psychiatric hospital in the 1950s. He attempted to immerse himself in the social situation of the hospital so that he could describe the rules of the social interactions he found there. He worked there for a year. He noted that there was a tendency for the behaviour of inmates to be interpreted as signs of illness once in the institution. So behaviour that might be thought of as challenging or rebellious outside of the hospital was seen as a symptom. An interesting example here is Swedenborg, who believed (as noted elsewhere) that he conversed with dead spirits and that the apocalypse had already occurred. Jaspers thought that he had “schizophrenia” and contemporaries said that if he had not been rich and famous he would have been regarded as mad, but he was socially effective and he acquired a group of followers who founded the New Church, based on his experiences. In The Varieties of Religious Experience, William James (1902) describes the experiences of conversion using case studies. He identifies one pattern as conversion following a “dark night of the soul”, which often involve a transformatory spiritual experience; an experience of sin, for example, which leads to religious conversion. Tolstoy, for example, had such an experience. These episodes could involve mystical experiences. Mystical experience could also occur at other times. Examples of mystical experiences include Charles Kingsley, who reports the following experience.

When I walk in the ﬁelds I am oppressed now and then with an innate feeling that everything I see has a meaning, if I could but understand it. And this feeling of being surrounded with truths which I cannot grasp amounts to indescribable awe sometimes . . . Have you not felt that your real soul was imperceptible to your mental vision, except in a few hallowed moments? (Inge, 1899 in James, 1902)

Another example is given by the report of J.A Symonds, the poet and author.

One reason why I disliked this kind of trance was that I could not describe it to myself. I cannot even now ﬁnd words to render it intelligible. Normalisation 37

It consisted of a gradual but swiftly progressive obliteration of space time sensation and the multitudinous factors of experience which seem to qualify what we are pleased to call our self. In proportion as these conditions of ordinary consciousness were subtracted the sense of an underlying or essential consciousness acquired intensity. At last nothing remained but a pure absolute abstract self. The universe became without form and void of content. But self persisted, formidable in its vivid keenness, feeling the most poignant doubt about reality, ready as it seemed to ﬁnd reality break as breaks a bubble . . . it served to impress upon my growing nature the phantasmal unreality of all the circumstances which contribute to a merely phenomenal consciousness . . . often I have asked myself . . . which is the unreality – the trance of ﬁery, vacant, apprehensive, sceptical Self . . . or these surrounding phenomena. (Inge, 1899 in James, 1902)

George Fox (1903), who founded the Society of Friends, began to be troubled as a young man by his observation of sin in the world. He left home and family in 1624 to travel through the country, trying to find inspiration and solutions to these concerns. He fell into a state of despair and sought out various priests to help him. He describes feeling guilty about leaving his family and feeling lost. His family wanted to marry him off or have him become a priest or a soldier. But he went travelling in search of some answer. He came through this period of despair. He discovered that the solution to his spiritual problems was to look to the “inner light”, the message of Christ in “openings” or as a voice, as a direct influence on him. He confronted the clergy in the pulpit, challenging their right to take money for preaching, and he converted many to his cause. He had a number of visions at various times. One of these occurred after he had been released from Derby prison and was walking through the country on his own. As he entered the city of Lichfield he had a vision of the streets filled with blood. He writes:

. . . I was commanded of the Lord to pull off my shoes of a sudden: and I stood still and the word of the Lord was like a fire in me and being winter, I untied my shoes and put them off: and when I had done I was commanded to give them to the shepherds . . . and the poor shepherds trembled and were astonished . . . and as soon as I came within the town the word of the Lord came unto me again to cry “Woe unto the bloody city of Lichfield!” So I went up and down the streets crying “Woe unto the bloody city of Lichfield” . . . as I went down the town there ran like a channel of blood down the streets, and the market was like a pool of blood . . . when I had done I considered why I should go and cry against that city . . . but after I came to see that there were a thousand martyrs in Lichfield in the Emperor Diocletian’s time . . . so the sense of this blood was on me, for which I obeyed the word of the Lord. (Fox, 1903) 38 Part one

Another vision was

. . . and I had a vision about the time that I was in this travail and sufferings that I was walking in the ﬁelds and many Friends were with me and I bid them to dig in the earth and they did and I went down. And there was a mighty vault top-full of people kept under the earth rocks and stones So I bid them break open the earth and let all the people out and they did and all the people came forth to liberty and it was a mighty place . . . and I went on and bid them dig again and Friends said to me “George thou ﬁnds out all things” . . . and I went down and went into the vault and there sat a woman in white looking at time how it passed away. And there followed me a woman down in the vault, in which vault was treasure. (Fox, 1903)

It seems here his visions and other religious experiences are a meaningful part of a journey of self-discovery. Given that Fox was to use these experiences so effectively in forming the Society of Friends it would be simplistic to label them as illness. Clearly, complex altered experience can occur in life-changing periods or during trauma. But maybe this is in some cases functional, a process possibly of growth rather than an illness to be thought of chemically. Emmanuel Swedenborg (Swedenborg, 1946) is a more difficult case. Karl Jaspers gives him as an example of a “schizophrenic”. Swedenborg lived the first half of his life as an inventor and scientist. He was offered a chair in mathematics in Sweden. He studied neurology and suggested a concept related to the neuron, but on entering midlife began to have visions, revelations and dreams. At 53 he was beset by these experiences over a three month period, and this culminated in him writing his “book of dream”. He believed that he could interact with angels and spirits and had the revelation that the apocalypse had already occurred in the previous year. He believed that God had commanded him to make his writings public. After his death his writings became the basis for The New Church, which still follows his writings today. Karl Jaspers thought Swedenborg to have been a “schizophrenic”, and some of his contemporaries said that if he hadn’t been so respectable he would have been thought to be mad. However, his ideas were found persuasive by others, and he carried on in others parts of his life with no obvious difficulties. It isn’t clear how labelling visionaries as “schizophrenics” illuminates anything. Furthermore, paranormal ideas have been taken seriously and investigated by scientists. Daryl Bem (2011), the social psychologist, published a review investigating the phenomenon of telepathy and indeed suggesting that there is evidence that these effects can be demonstrated in the laboratory. These results have been disputed by other psychologists, who have suggested that we alter our means of analysing experimental data. Other investigators have failed to replicate Bem’s results. Of course, if these effects were found to be genuine it would make distinguishing psychotic from sane experience considerably more difficult, but the point here is Normalisation 39 simply that these ideas are present in the general population and, indeed, in educated and refined people. That there seems to be a continuum of experiences speaks against the idea of separate psychiatric illnesses. It may be that the ability to function is more helpful when deciding if people need care or protection.

Psychotic experiences that are less normal That people who do not have any psychiatric disability can report a range of experiences which have been taken to be distinctive to psychotic states has been an important spur to cognitive therapy with people with psychosis. However, there are some psychotic symptoms that are more difficult to see in this way and some experiences which do not readily lend themselves to a Maherian account. One such experience is that of passivity phenomenon. This is the experience of alienation from one’s thoughts or actions. The person claims that other people put thoughts and feelings into their mind. These experiences are difficult to understand as part of the normal continuum or as rational explanations of unusual experiences. The chief difficulty here is that it seems to be a contradiction to say that someone else’s thoughts are in my mind. Also there are acute states in which a person feels completely lost in a changed world.

Normalisation as a strategy Normalisation was developed as a strategy for engaging clients in treatment for psychosis. Kingdon and Turkington (2005) were psychiatrists responsible for patients in a catchment area in the North of England. Their report on their use of cognitive therapy to treat clients with “schizophrenia” was an important turning point. They reported using a normalising rationale with clients. In general a medical model approach to psychosis endeavours to educate clients with “schizophrenia” (patients) into seeing their symptoms and problems as the result of an imbalance of synaptic transmitters, and sometimes other organic impairment of their cognitive ability. The problem with this is that it often ends up in a battle between the psychiatrist and the patient, who doesn’t accept a) that they are ill, or b) even if they do accept that they are ill they do not accept that the beliefs they have are part of the illness. The essence of this practice is to describe psychotic symptoms as either related to environmental stressors or as extensions of experiences which are common in the general population. So the fact that under environmental stress people are more likely to experience hallucinations or that some people believe in telepathy is emphasised. This is a very different approach from the standard psychiatric approach, which can so often result in a stalemate. It is clear in their writings that Kingdon and Turkington regard medication as central to their therapy, but that a normalising approach is possibly better at engaging clients in taking medication than an illness- based approach. One possible problem can be when the client takes normalisation further than the intent of the therapist and concludes that as this is all very normal 40 Part one he or she doesn’t need to take medication, as they don’t have a problem. This doesn’t happen very much.

Example of normalisation in practice I saw one of my clients, Jill, over a three-year period. She was troubled by voices which would often occur when she heard some other sound. She was also troubled by pervasive misinterpretations of the meaning of events around her. Events were interpreted in the light of her prevailing delusion that because she had reneged on a drug deal some 20 years earlier she was to be kidnapped and tortured by the criminals whom she believed to have been sent to prison. She lived in a one-room bedsit in the suburbs of Sydney and she continually heard voices coming through the wall calling her a nonce (child molester) and threatening to kill her. She took these voices to be people who lived in the adjoining flat. She spent her days mainly in her room. She only ventured out to get food or occasionally to visit her one friend. Therefore her sessions with me assumed a greatly increased role in her life in comparison with therapies with clients with other diagnoses, and less marked social isolation. Jill had voices that were triggered by external sounds. Often at the end of our sessions she would close the door and then after a few seconds open the door again to ask me if I had called her an insulting name after she had closed the door. She believed that she had “schizophrenia” and was subject to hallucinations. The only question was, in a particular case, whether it had been an hallucination or whether, for example, I had called her “a bleeding nonce”. We took to reality testing her beliefs so we went out for coffee and Jill looked tense as people spoke and I felt tense in case she responded to perceived vocal insults with retaliation. One attempt at normalisation saw us visiting the Tate Gallery to see the “Ghost of a flea” by William Blake, who I assured Jill had also lived in London and who had also been the subject of visions (that is to say, the ghost of a flea which he had seen at a séance). The commissioner of the painting reported the process of drawing the flea from the vision in the following way . . .

As I was anxious to make the most correct investigation in my power, of the truth of these visions, on hearing of this spiritual apparition of a Flea, I asked him if he could draw for me the resemblance of what he saw: he instantly said, “I see him now before me”. I therefore gave him paper and a pencil with which he drew the portrait . . . I felt convinced, by his mode of proceeding, that he had a real image before him, for he left off, and began on another part of the paper, to make a separate drawing of the mouth of the Flea, which the spirit having opened; he was prevented from proceeding with the ﬁrst sketch, till he had closed it. (Bentley, 2003)

As well as normalisation I was also setting up reality tests. Would I hear the voices which she heard? Actually her belief was quite sophisticated, as she knew that Normalisation 41 sometimes she was hearing voices, so that if I could not hear the voice this didn’t really show that all of her voices were hallucinatory, just that this one was. Schreber (whose autobiography of his psychotic breakdown was used as a case study by Freud) read Kraepelin and argued exactly the same point. That some people hallucinate doesn’t mean that no one hears and sees spirits. (Although we may doubt that these experiences are real that doesn’t make them psychotic.) One way of thinking about the reality tests I carried out with Jill is that they were empirical tests of a hypothesis, in much the same way as one tests a scientiﬁc hypothesis, and this would be the original cognitive way of thinking about this, and was my way of thinking about these investigations. If this is the explanation the real therapy comes from the cognitive technique. However, it is all a question of what is form and what is ground. It seems to me that the fact that Jill had never talked about these experiences and her ideas about them at great length with anyone before was important. These experiences set Jill apart from everyone else. She couldn’t speak of them without being invalidated by other people and her experiences led her to become very suspicious of other people. So I think that when she was opening the door after the end of our session and returning to ask if I had called her a nonce or threatened her, this was also an interpersonal change. This was the beginning of a relationship in which she could begin to be honest about her experiences and fears and therefore be less isolated. (See the chapter on psychoanalysis.) Normalisation is a helpful strategy in working with people, and there seems to be good evidence for psychotic experiences occurring in the general population and not only during periods of “psychiatric illness”. But although we may not be able to distinguish this by a clear dividing line, clearly people can be in grossly confused and disoriented states of mind and the fact of a continuum doesn’t help to explain this. 4 COGNITIVE NEUROPSYCHOLOGY OF “SCHIZOPHRENIA”

The models of rational-emotive therapy (Ellis, 1962) or Beck’s cognitive therapy (1976) or a normalising dimensional account of psychosis have been very useful in promoting collaborative psychological therapy with people with psychotic experiences. Psychotic experience does indeed occur in the general population, more frequently in people with a range of emotional disorders (not just the major psychoses) but also in people for whom it is not a problem. Psychotic people can be engaged in a collaborative therapy. However, these models do not offer an explanation of the occurrence of hallucinations. They do not explain some of the more bizarre psychotic experiences such as Cotard’s delusion, where the person maintains that they are dead or having passivity experiences such as thought insertion, thought broadcast, or that their feelings or movements are under external control, or that they are an apple or some other object, or some of the rich descriptions of psychosis given by Jaspers. Some of these beliefs seem, on the face of it, to be contradictions, and therefore not derived from other propositions logically. It is possible that these explanations could be thought of as a non-rational reaction to some other experience. Gerrans (2002) has suggested that Cotard’s delusion is a reaction to a deeply depressed mood which is then misattributed to being dead. This seems to be treating man a little too much like a scientist. In deep depression we know from clinical experience that people will believe all types of irrational things which seem largely an expression of the person’s mood. Neurocognitive models of “schizophrenia” or psychosis are attempts to explain the symptoms of psychosis psychologically. In this chapter I will review two of the most inﬂuential of these theories.

Frith’s cognitive neuropsychology of “schizophrenia” Chris Frith’s (1992) model of “schizophrenia” has continued to be influential. Along with Hoffman’s (1986) model of auditory hallucinations it is probably the Cognitive neuropsychology of “schizophrenia” 43 best neuropsychological model of “schizophrenia”, but it doesn’t really get referenced in the cognitive therapy models of psychosis. The model elaborated in his book “The Cognitive Neuropsychology of Schizophrenia” is actually the last of a number of different models Frith has produced. He is trying to give an account of the symptoms of “schizophrenia” by developing a model of the underlying cognitive mechanisms, i.e. information-processing mechanisms. He is also looking to try to relate these underlying information-processing mechanisms to the functioning of the brain, although this is not a large part of his model, and he suggests that there are similarities between some of the symptoms of “schizophrenia” and symptoms of frontal lobe damage. However, in the main his theory is of the malfunctioning of underlying sub-personal systems. But it is an implicit part of his model that dysfunctional brain processes are responsible for the dysfunctional information processing he describes. His model really rests on the hypothesis that there are discrete mental illnesses and that “schizophrenia” is one of these. If it turns out that, for example, “schizophrenia” doesn’t exist then Frith’s theory would need some radical adjustment. He does begin with descriptions of particular symptoms before proposing a theory of “schizophrenia”, but he is thinking of these as, for example, the voices of schizophrenia, not the voices, for example, of spiritualists. He begins by giving explanations for three different types of symptoms in “schizophrenia”: 1) disorders of action (largely negative symptoms), 2) hallucinations and delusions, and 3) speech or thinking disorders. He suggests that negative symptoms are caused by a lack of generating intentions to act. He sees this as similar to deficits in patients with damage to the frontal lobes. The person with negative symptoms can still respond if cued to carry out behaviour. They have difficulty in generating action spontaneously. He explains auditory hallucinations in terms of a deficit in self-monitoring. Frith holds an output theory of auditory hallucinations (or at least most auditory hallucinations; he accepts that some hallucinations may be explained in a different way). He rejects the idea that all auditory hallucinations are perceptual in nature (mainly on the grounds that clients often don’t report these experiences as similar to hearing things (Sedman, 1966; Chapman and Chapman, 1988)). He suggests that auditory hallucinations are the person’s own thoughts. The person who is having hallucinations is talking to him- or herself. If auditory hallucinations are not a perceptual phenomenon but are the person’s inner speech, this raises the question of why they do not recognise that this is their inner speech. Frith suggests that is due to a difficulty in self-monitoring inner speech. If auditory hallucinations are misattributed inner speech then he suggests that they may be similar to the phenomenon of thought insertion. In thought insertion the person clearly misattributes his or her thoughts to someone else (this is more or less a definition of thought insertion).

Frith’s comparator model Frith suggests that verbal hallucinations and thought insertion are the result of either self-talk which is not identified as self-talk, or thinking which is not identified as 44 Part one belonging to the person. He takes as his starting point the observation that in perception the brain compensates for voluntary movement of the eye to give us a consistent image of the world. Frith then suggests that a similar process occurs for all actions; that there is a monitoring mechanism which keeps track of our actions and the effect that they have on the world. So in the case of vision our brain adjusts the image that we see on the basis of neural discharges sent to the eye to move. If the eye is moved by some other means (if you push the eyeball with a finger, for example) the world appears to move, but if we intend to move our eye then the image of the world appears stable. He suggests that these positive symptoms of “schizophrenia” occur when the system of monitoring does not function. He draws on Sherrington’s idea of a comparator (which Sherrington developed to explain certain symptoms of Parkinson’s disease). Intentions to act are compared with actions. So that in the case of thought insertion or verbal hallucination the person intends to think something or to say something to him- or herself in inner speech. However, the comparator mechanism fails, so the person is aware of thinking something or saying something to themselves but not aware that they intended to do this. This results in the experience of verbal imagery or a thought which the person does not recognise as one that they intended. This is the basis of the experience of thought insertion or verbal hallucination. Someone is thinking but it is not me. Someone is speaking (in inner speech) but it is not me. He also explains other passivity phenomenon in the same way, e.g. believing that your feelings have been caused directly by someone else’s will, or that your sensations are caused by someone else, or that one’s bodily movements are under someone else’s control. Von Helmholtz suggested that this process involved an efference copy. The intention to move one’s eyes was part of a feedback system which gets incorporated in the final perception. It is also supposed to be this system that makes it impossible to tickle oneself. Frith suggests that this observation implies that the brain has a way of monitoring the outcome of actions to distinguish between what a person makes happen and what simply happens to a person. This helps to distinguish between raising my arm and having my arm raised. He suggests that as well as a system for monitoring the outcomes of our actions to distinguish between those events that we have caused and events that we have not caused, there is a system to monitor our intentions to act. The purpose of this system is to distinguish between actions which are the result of our intentions which are caused by our own goals and plans, and those that are a reaction to stimuli in the environment. Defects in this system would result in delusions of control. He suggests that we have a sense of effort when we think. We choose to think about certain topics and direct our thoughts onto certain themes. If we did not experience this sense of effort we would conclude that our thoughts were not our thoughts and had been inserted into our mind. Voices are the result of a failure to monitor the outcome of our actions. Hearing a voice would be an event caused by our intentions but not recognised as such by the monitoring system. This can lead to either auditory hallucination or to thought insertion. Frith argues that although thought insertion is classified as a delusion it would be better Cognitive neuropsychology of “schizophrenia” 45 thought of as an abnormal experience. Frith mentions that this must mean that there is something about our experience of our own thoughts which marks them as our thoughts. The other group of symptoms that he explains are communication difficulties. This is what is traditionally called thought disorder, and there is a question about whether the problem is to do with thinking errors or communication errors. Frith presents evidence that the speech difficulties that people with “schizophrenia” present with are expressive difficulties rather than receptive difficulties. There is an experiment he cites in which people with a diagnosis of “schizophrenia” are asked to point out a colour from an array of colours by description. People with “schizophrenia” found it difficult to explain to the other person which colour to pick out, but they had no difficulty in picking out the correct colour when someone else described it to them. This tends to suggest that the language problem is expressive. He argues that the communication difficulties are difficulties in the practical aspects of language use. The person with “schizophrenia” has difficulty in appreciating what the other person needs to know or doesn’t know and which needs explaining in order to understand the communication. So the person has difficulties monitoring the intentions of other people. He then suggests that this difficulty in understanding or reading the intentions of others can also explain ideas and delusions of reference and paranoid delusions. The schizophrenic person has trouble with communication because of the pragmatics of the interaction. They can’t work out what the other person knows or doesn’t know to effectively communicate. Delusions of reference involve thinking that other people are trying to communicate with the person when they aren’t. Paranoid delusions, he suggests, arise because the person cannot read other people’s intentions and misunderstands their intentions towards him or her. Having begun by arguing that it is most fruitful to try to explain particular symptoms using neurocognitive models, he finally goes on to suggest that his three types of explanation for schizophrenic symptoms can be unified.

Metarepresentation Frith suggests in the conclusion of his book that the three processes that he hypothesises to account for the symptoms of “schizophrenia” (namely inhibition of willed action, difficulty or lack of ability in self-monitoring thoughts and intentions, and difficulty in monitoring other people’s intentions) can be understood as all manifestations of the same cognitive difficulty. He suggests an underlying difficulty in metarepresentation or, equivalently, an impairment in the theory of mind. By metarepresentation he means the ability to form a representation of a state of mind. Because Frith thinks of states of mind as representations of the world, he thinks of the ability to represent these states of mind as “metarepresentation”, and in his model the primary representations are thought as being localised in particular areas of the brain. This fits with his model of the brain as a computer, running software. He points out that the content of a metarepresentational statement such as “I believe 46 Part one

‘it is raining’” is not held to be true or false by reference to the facts. Brentano claimed that this was a defining characteristic of the psychological. That mental states are “about” something, and that a statement about a mental state’s truth value doesn’t depend on the truth value of the embedded statement. So whereas the truth of the statement “I am going to get wet because it is raining” is affected by the truth of the statement “it is raining”, the truth of the statement “You believe it is raining” is unaffected by the truth of the statement “it is raining”. Of course, it does not follow from that fact that mental processes depend on the brain that particular statements are localised in particular areas of the brain. This only seems at all plausible if one is using the model of a computer to think about the brain. Baron-Cohen (Baron-Cohen and colleagues, 1985; Baron-Cohen, 1997) had suggested that a deficit in the “theory of mind” might explain the symptoms of childhood autism. The hypothesis is that we have an innate ability to react to and to see other people as having minds. Premack and Woodruff (1978) found that chimpanzees were able to predict how people would behave in problem-solving situations (such as reaching a banana which was out of reach with a stick). They suggested that the best way to explain this was by assuming that the chimp had a “theory of mind” and imputed intentions and motives to the person. They pointed out that this was true of people. In his book “Mindblindness” Baron-Cohen describes in detail how this might work, with an inherited tendency to interpret movements of a particular kind as evidence of voluntary movement, intention and so forth. Chris Frith suggests that there may be overlap between “schizophrenia” and autism on the basis of the underlying cognitive disability or impairment. Clearly, people have the ability to understand other people’s mental states. It is considered a theory of mind, as mental processes cannot be directly observed. One consequence of losing the ability to use a theory of mind is that one cannot understand other people’s mental states. In addition, Frith argues that in “schizophrenia” the ability to read one’s own mind is lost. I want to point out in passing that an alternative theory here is that we can directly observe other people’s mental states. In real life we don’t feel we are inferring anything if we read someone as in a rage for example (Austin, 1962). (I will come back to this in the next chapter. Information- processing models often mean that these processes are sub-personal, but whether that makes sense is controversial.) Frith argues that the loss of the ability to mentalise causes the symptoms of “schizophrenia”. Negative symptoms are caused by the person not having access to their goals. They have goals but because they do not have conscious access to their goals they cannot act in accordance with these goals. The loss of the ability to mentalise has other implications. The person cannot access their own intentions, so they do not know what they intend. This results in the person not knowing that they, for example, intended to think something or intended to do something. So someone may intend to say something but then not recognise that they intended to say it and therefore report it as someone else’s voice or as someone else’s thought. Not being able to mentalise about other people’s state of mind means that the person may misinterpret other people as intending to communicate when they are Cognitive neuropsychology of “schizophrenia” 47 not communicating or may misconstrue the intentions of others. Frith mentions that the person may think that the other is trying to conceal their intentions and therefore become suspicious because of this act of secrecy. Frith then adds that because of the inability to mentalise, the content of a statement may become dissociated from the other part of the statement. The person is not aware of thinking “Jones thinks ‘Chris is stupid’” and therefore is simply aware of the content “Chris is stupid” and becomes aware of this rather than the metarepresentation. This being a third-person hallucination. If John believes that Fred thinks he is stupid he suggests that this can lead to an hallucination by a similar process. John believes “Fred thinks that ‘you are stupid’” leads to the experience of being aware of the content “You are stupid”, experienced as a second-person hallucination. Of course, this is a bit of a stretch, because the relevant initial belief wouldn’t be “Fred thinks ‘you are stupid’” but “Fred thinks ‘I am stupid’”. It would be an unusually academic way of expressing this to put it as “Fred thinks ‘you are stupid’”. Furthermore, the meaning of this statement is unclear until it is specified that the “you” in his mind is actually me (because it could clearly be a range of people). His model doesn’t explain some features of psychotic experience. Why are hallucinations in the third person if we discount this account of embedded thoughts? His model explains thoughts being experienced as not owned by me, but why do people attribute the thoughts to others? In the case of a monitoring mechanism for the vision and eye movements, the function is clear. Movements of my body can be produced by my action or by other events and it is useful to differentiate between these two cases (so I know if I am moving or the world is moving). But what could the reason be for a mechanism to monitor our intended thoughts? Why does the person who experiences the altered perceptual input not conclude that there is something changed about them rather than the world? Is this actually how we identify our thoughts as ours? In the usual case the answer must be no, this is not how we identify our thoughts. One can imagine a situation in which when various thoughts come into my head I sort them out as belonging to different people depending on the content of the thought, but clearly we are not in this situation.

Information-processing model of “voices”: Ralph Hoffman Another highly influential cognitive neuropsychological model of psychosis was proposed by Ralph Hoffman (1986). Hoffman suggested that an output theory of hallucination fits the data better than an input theory of hallucination. His version of this is that verbal hallucinations are not really hallucinations but are inner speech which has been misattributed. The person is speaking to themselves but misattributes the inner voice to someone other than themselves; they perceive the inner voice as belonging to some outside agent. Actually his theory is somewhat more complicated than this. Hoffman argues that during clear, alert consciousness we are aware that our thoughts belong to us, as they are directed and fit with our purposes and 48 Part one intentions. When we are relaxed or in otherwise drowsy states of mind we can have thoughts which are not directly in line with our intentions or desires. For example, we may daydream. In drowsy states of mind thoughts may occur to us which do not fit with our intentions and wishes. However, in an alert state of mind thoughts are expected to fit with our intentions or desires, and if thoughts occur which do not fit with our intentions and desires the thoughts are not identified as “mine” and are experienced as alien, as belonging to someone else. This caveat is to avoid the implication that daydreams should be identified as other people’s thoughts because they are not consistent with our hopes and dreams. If I have thoughts which do not fit in with my plans and intentions and if this occurs during alert consciousness I will perceive these thoughts as alien and perceive them as alien voices. Hoffman suggests that there is a sub-personal discourse-planning process that plans our discourse and which makes our talk fit in with our underlying intentions and desires. In “schizophrenia” there is a malfunction in this discourse-planning procedure. This is what gives rise to formal thought disorder or language-generating difficulties. So verbal hallucinations are explained using the same mechanism that causes the thought disorder in “schizophrenia”. The process by which verbal imagery is identified as being alien is by detecting that it is not what is expected given the plans and intentions of the discourse- planning sub-personal process. Hoffman suggests that this process fits well with a Maherian explanation of delusion. It is a normal process and the conclusion is reached by a normal process. The argument here, as in Frith, moves between a sub-personal process and a personal process. When the person becomes aware that they are saying things which were not planned as part of the discourse-planning process, this sounds like a sub-personal process, and all that the person would be aware of would be the consequences of this process. If the person was to become aware that what they were saying to themselves was radically opposed to his or her purposes, values and goals and therefore concluded that they had not said it to themselves, this would be a personal process and either a conscious inference (or an inference that one was capable of becoming aware of). One difficulty here is the homunculus problem. Hoffman (and this also applies to Frith) is explaining how we recognise that our discourse fits with our intentions and goals via a discourse planner; he says, “It is almost impossible” to conceive of how we could speak in a coherent way if it were not for this discourse having been planned prior to beginning to speak or think. But the problem here is that if thinking or speaking was planned prior to speaking or thinking by a process which worked out what was to be said and then compared what was said to what had been planned, then this process too would seem to need to be planned, and so on ad infinitum, an infinite regress. And in the end we have to have a process of discourse planning which is not explained by a further, previous piece of discourse planning. And if this is true at some point, why should it not be true at the beginning? On a related issue, to the suggestion that for a thought to have meaning we must have an associated mental image, Wittgenstein (1958) asked if it is necessary to imagine a red patch in order to understand the command “Imagine a red patch”. Cognitive neuropsychology of “schizophrenia” 49

Another problem is highlighted by obsessional thoughts, although it is present for other thoughts too. People regularly have thoughts that they would dismiss as silly or out of keeping with their intentions or values. The religious client who thinks “Christ is a bastard” disavows the thought and does not intend to think it, but is in no doubt that this is his or her thought. And there are of course many other thoughts which we have and dismiss as meaningless and which we did not deliberately think which we have no doubt are our thoughts. Another complication is that the content of verbal hallucinations does not seem to be random. If as in Hoffman’s account the verbal hallucinations are randomly produced, mirroring the randomness of thought disorder, one would expect the resulting hallucinations to be random rather than make sense and often focussed on a particular theme. There is a further step in hearing voices and in experiencing thought insertion beyond identifying them as not fitting with my intention. This is attributing the thought or inner speech to someone else rather than oneself. It is one thing to identify a thought as not mine; it is another thing to identify it as someone else’s thought or speech. Here there is a model of the person being aware of various images or pieces of language and then deciding who to attribute the language to. But of course in the ordinary course of events we never have occasion to ask this question. We don’t, as a matter of fact, find ourselves wondering if some inner speech that we have become aware of is our own or someone else’s. We do identify our thoughts, feelings and sensations as belonging to us and other people’s thoughts, feelings and sensations as belonging to them. But pretty obviously we don’t do this by identifying them as such in our stream of consciousness. Our system of being able to identify our mental states and other people’s mental states is not in fact based in a personal or sub-personal system but in an interpersonal system. Although, I don’t pick out my own thoughts and feelings in anything like the way that I pick out others (or maybe I don’t pick out my own thoughts and feelings at all). Stephens and Graham (2000) and Dennett (1986, 1991) suggest that if I found myself making a simple mistake I can dismiss it as a slip of the tongue or an error, but if I found myself engaged in a complex task which seems goal-oriented but to someone else’s goals, I might well begin to describe these actions as someone else’s actions. Here, though, it is not really clear what we would say. That is the Wittgensteinian example of the person who has a different personality on different days (1958). If I found myself acting in accordance with someone else’s intentions and goals I could really say anything, as our concepts don’t fit this example. In any case, not identifying speech as fitting with my own discourse plan, or not matching the efference copy sent to the comparator, isn’t enough to explain the attribution of the speech to someone else. And If I hear a voice (and it isn’t my voice) then this implies that it is someone’s voice, i.e. someone else’s voice is implied by hearing a voice. Hoffman suggests that other symptoms of “schizophrenia” can be explained in a similar way. Visual hallucinations, for example, do occur in “schizophrenia” and he suggests that this may be due to a similar process where higher-order visual 50 Part one processing about the nature of objects is disorder and visual imagery is confused with perception. For Hoffman, the person produces unintended inner speech which because it is unintended and occurring in a wakeful state is not recognised as belonging to the person, and is therefore interpreted as belonging to someone else. For Frith the difficulty is in the process that monitors thought or inner speech, so that an intended action is not perceived as intended. He suggests that there is a sense of effort in normal thinking which is absent (which seems to point to a conscious process rather that an unconscious process). For Hoffman, the problem is with the randomly produced thoughts in the planning stage, which are then not perceived as fitting in with the discourse planning. The thoughts being experienced as unintended are then perceived as alien because of this. On both accounts, however, it is unclear why the psychotic person would elaborate these experiences into a delusion that someone else was talking or that someone else was thinking in their head. A difficulty with Frith’s self-monitoring system is that it is not at all clear what such a system would be doing. Monitoring the intended movements of my eye functions to determine whether it is the world or my body which is moving. However, I could never be in a position to monitor my thoughts or inner speech and decide that they are not my thoughts. We do distinguish between our thoughts and feelings and those of other people, but it is not by introspective monitoring. Frith’s account implies that I can intend to think something but then only realise that I intended to think it by a later process of monitoring my thoughts. Also it is clear that however we determine what someone else is thinking it cannot be by a comparator.

Difficulties with Hoffman’s theory Hoffman is concerned to explain how verbal hallucinations could be externalised speech using an information-processing model. He does not claim that this is a complete explanation of verbal hallucinations. Some features of verbal hallucinations are not well accounted for by this misattribution theory. Voices are repetitive and often talk about personally important issues, rather than random issues. If voices are explained as a consequence of thought disorder, why do they usually say meaningful things to the clients? This doesn’t seem to fit with the suggested mechanism. Similarly, voices can be combined with visual hallucination on a consistent theme. Usually this is not the case and the person simply hears a short sentence, but some people do experience visual and verbal hallucinations on a consistent theme. Some people report hallucinations with sensory characteristics. People often have multiple voices and know that the voice is the voice of a particular person. If voices are inner speech misattributed why and how does the person identify different people. Often they say that they can differentiate the voices by the way that they sound. Clients can sometime have visual hallucinations of the same person as the voice. Voices speak to clients in the second or third person rather than the first person. Speaking to oneself is usually in the first person and it is not clear on Hoffman’s Cognitive neuropsychology of “schizophrenia” 51 account why this would be so. Frith’s idea that part of the sentence is detached seems to imply that meaning is located in some place in the brain. But this doesn’t seem like a very likely explanation of how we “represent” objects, which seems more to do with being able to operate with language. Furthermore, quite a lot of thinking doesn’t involve any speech at all. Hoffman suggests that a Maher-type explanation is involved in the process of this externalisation. If this is so, then potentially this could lead to a cognitive intervention on the interpretation of the verbal imagery that is taken for other people’s voices. Actually, many psychotic people do end up thinking in this way. Dennett suggests that verbal hallucinations can be explained simply as misattributed self-talk, if the self-talk is not consistent with the person’s goals, without having to invoke any suggestion of a self-monitoring mechanism, and thus avoiding the infinite regress problem. However, as Hoffman points out, we can easily think things which are counter to our goals and plans without thinking that this is someone else’s voice. Knowing that our thoughts are our thoughts is not the product of a process of deduction or observation. No one usually has doubts about whether they are having their own thoughts. To seriously question if our thoughts are our own would be seen as a sign of a mental disturbance. It is not clear on Frith or Hoffman’s account why the misattribution of inner speech as verbal hallucination or as thought insertion is developed into a delusion. A visual migraine does not result in people thinking that the world is dissolving. Ordinarily we do not go through a process of identifying our own inner voice as our voice. We don’t usually have to identify our voice at all. There is an assumption behind the Frith/Hoffman model that we attribute states of consciousness to ourselves and to others in a similar way. Here there is a difference between explanation on a personal and sub-personal level, so whether this makes sense may depend on what we make of sub-personal processes (this is discussed in the following chapter). Philosophers have wondered how we can have the same predicates with the same meanings for our own and for other people’s mental states when the process of learning about the application of these words is so different in the two cases. Another difficulty with this model is the non-specificity of psychotic symptoms. If the process is supposed to explain the psychotic symptoms of “schizophrenia”, then what of similar experiences in those who are bi-polar or depressed, or have borderline personality disorder, or in the general population. That is to say if the category of “schizophrenia” does not define a natural kind then are the explanations of Frith and Hoffman to be applied to all psychotic experiences or just to those of some sub-category, whatever that might be. In so far as these are explanations of schizophrenic symptoms, if there really is no such thing as “schizophrenia” or separate mental illnesses then the theories lose their credibility. A client of mine, who I discussed previously, was a 60-year-old woman who had a diagnosis of “schizophrenia”. The diagnosis was based on chronic auditory command hallucinations, delusions, visual hallucinations and social withdrawal. She had one brother who lived in a different part of the country and whom she saw once a year. She rarely left her house and suffered from chronic low mood. 52 Part one

She had become psychotic in her early twenties and had not left home. Her voices told her to self-harm and to kill herself. They told her that she was not worthy of life. She also had visual hallucinations of her uncle and a group of hooded figures whom she identified as the Satanists. Her father had died when she was 12 and her mother had died when she was in her 30s. She agreed with what her voices told her. She had been sexually abused as a child and when she told her family about it they blamed her. In therapy she attended regularly for several years but left each session after half an hour. She was continually in conflict about whether she wanted to talk about her past abuse. Part of her wanted to tell her story but she was anxious about talking about it. During the sessions she was often hallucinated, with voices telling her not to trust me and that she was to blame for having being abused. Thinking about the theories of self-alienation we have been discussing, there are certain features of this client’s situation that are not well explained. It seems clear that the various symptoms she presents with are part of a gestalt. She had unresolved feelings about having been abused and was hearing voices blaming her for this and telling her that she was worthless and should harm herself. Her visual hallucinations were of the person who had abused her or of evil persecutors. During a therapeutic dialogue with the voices it became clear that she saw the motive of the persecutors as purely evil. The various symptoms seem to be part of a more general problem. The theme of the voices and the delusional beliefs is not random, as might be predicted by randomly generated thoughts caused by associative problems. The voices don’t seem to express her undetected intentions. Rather the voices seem more like parts of her conscience attacking her. Her trauma history doesn’t, on the other hand, explain why her feelings about this trauma are expressed through psychotic symptoms. Many people who are abused present with non-psychotic symptoms. Most people who are abused present with no symptoms at all. But an account of her symptoms singularly would leave out the fact that these symptoms (social withdrawal, voices, visions, paranoid delusions, self-harm and suicidality, chronic low mood) are all related to each other and part of a coherent story.

Bentall, Morrison and source monitoring Anthony Morrison (1995) has suggested a cognitive model of auditory hallucinations which in many ways is an extension of Hoffman’s model but with a crucial difference. In his model it is a question of discriminative bias in source monitoring that leads the person to wrongly conclude that they are hallucinating. Bentall has suggested that perception of voices as voices rather than inner speech may be a matter of bias in source monitoring. On this model I think the suggestion is that we deduce whether we are having inner speech or hearing a voice by working out what the source of the input is. Much of the experimental evidence for this approach has come from the study of memory. But, of course, we often have the experience of not being sure about the origins of memory (do I remember that event or just think I do because I have been told it happened, particularly events in childhood). But we don’t do anything like this with regard to our current thoughts (unless we are having Cognitive neuropsychology of “schizophrenia” 53 a breakdown, that is). Not all thought is inner speech. If I decide to go to the shops I don’t have to say this to myself, I may just look in the cupboard for some beans, find they aren’t there and go out to the shops. It would be odd to think that whether I had decided to do this was the result of a deduction about the source of the intention. And it would be just as odd if I did put this into inner speech to think that I then had to work out if that intention was mine or someone else’s now it was in words. This model of the relationship between myself and my thoughts seems to be essentially misguided. The verbal hallucinations as inner speech hypothesis has been developed in a different direction by clinical psychologists Richard Bentall and Anthony Morrison (Bentall and Slade, 1985; Morrison and Haddock, 1997; Bentall, 2003). Bentall argues that the externalisation of voices may result from a selection bias, so that negative inner speech is externalised. Bentall has suggested that hallucination may be explained by bias in source monitoring. By this he means the process of distinguishing our thoughts, feelings and images from our perceptions. Work on this has been conducted by looking at people’s ability to distinguish names that they were told from names that they came up with themselves. However, distinguishing whether one thought of an idea or whether it was suggested to you or whether you read it is a very different thing from working out if you are seeing something or hallucinating it, of course. In everyday life we often remember names we generate and names that others generate and which we remember. It does not follow that the same process takes place in the case of deciding if the room I am sitting in right now is a real perception or, say, a figment of my imagination. Generally, we don’t ever deliberate on whether we are seeing or imaging something. And the fact that in special cases we get this wrong cannot be generalised to suggest that we are always doing this (Austin, 1962). One reason this is interesting is that it could be that this selection bias could be explained in terms of someone’s motivations and goals, whereas the model of Frith and of Hoffman really has as an unexpressed postulate that the cause of this information-processing fault is probably organic. If externalisation is due to a bias in selection this might be in service of some goal of the client. Bentall has suggested that one part of the causes of delusions is the attribution style of the person. Developing this line of thought, Anthony Morrison (1997) suggested that verbal hallucinations can be understood using a model which has been developed for understanding obsessional thoughts. He suggests that verbal hallucinations could be disavowed obsessional thoughts. Put in cognitive terms he suggests that verbal hallucinations are obsessional thoughts, but are not recognised as thoughts but are taken to be other people’s voices due to a belief of a particular kind. This is a metacognitive belief. In this case by “metacognitive” Morrison means that the person has a belief that thoughts which do not fit in with one’s desires, goals and beliefs do not exist. That is the metacognitive belief that obsessional thoughts do not exist. When intrusive thoughts occur they are judged as coming from some other agent because of this belief. He describes a self-reinforcing process to explain the occurrence of verbal hallucinations. 54 Part one

It is part of the model that intrusive thoughts occur commonly in the general population as well as in people with emotional disorders. An intrusive thought is triggered either internally or by something external. The thought generates cognitive dissonance (because it is an intrusive thought and therefore not consistent with the person’s beliefs, morality or goals). Because of the belief that intrusive thoughts do not exist it is externally attributed, i.e. it is seen as someone else’s voice. Following this belief about the voices will generate an emotional response. If this emotional response is negative it may then trigger further intrusive thoughts. Morrison acknowledges that some verbal hallucinations are neutral. In this model it is a little unclear how positive voices are perpetuated. Presumably, if intrusive thoughts are generated by negative affect then positive affect is going to reduce the chance of further intrusive thoughts. However, a question arises about how this fits with the everyday phenomenology of thinking, in particular with obsessional thinking. Do we conclude on the basis of our belief in the possibility of having thoughts which are counter to our moral beliefs that these are indeed our thoughts as opposed to someone else’s voice? Isn’t it more automatic than this? Isn’t our way of finding ourselves listening to someone else’s voice tied up with hearing it and being able to localise it in space? Unless the suggestion is that hearing something is about monitoring sources, but here the danger of Dennett’s infinite regress arises, because who is supposed to be doing the monitoring? 5 PHILOSOPHICAL PSYCHOLOGY

In this chapter I will discuss Karl Jaspers’ phenomenological account of psychosis and review some philosophical critiques of the work of Frith and Hoffman which have interested some contemporary philosophers. Finally, I will brieﬂy touch on some ideas about how we attribute mental states to ourselves and others and suggest this might be helpful in understanding passivity phenomenon. Some of the issues discussed in the previous chapter have caught the interest of philosophers. In this chapter I will discuss some of the debate around the implications and difﬁculties of explaining thought insertion, but I will begin by discussing Karl Jaspers’ (1997) phenomenology. There are some delusions which are not so easily explained as rational explanation of unusual experience: thought insertion, loud thoughts or feeling that thoughts can be taken out of one’s mind, for example. Also Cotard’s delusion where the person asserts that they are dead or do not exist is hard to explain as a rational deduction (given that it is a contradiction). Thought insertion, to take another example, seems on the face of it to be another contradiction. To believe that someone else has literally put thoughts into my mind seems to be a self-contradiction. I am having thoughts that are not mine, given that my thoughts are the ones in my mind seems to be nonsense, and as nonsense not derivable as a conclusion from anything. No experience that I could have would justify the claim that someone else’s thoughts were in my mind, because it is unclear what the truth conditions of the statement could be. First-person statements are immune from error of reference. If I say you said you were leaving, I can be wrong about what was said and also who said it. However, if I say I am thinking of leaving, I can be wrong about the content of my thought (I may be pretending to myself that I am thinking of leaving) but I cannot be wrong about it being me that is thinking it. And yet this is what the person with thought insertion says. 56 Part one

Karl Jaspers’ phenomenology Karl Jaspers is often identiﬁed with the view that psychotic experiences are only to be thought of as biological symptoms. Actually, Karl Jaspers becomes a bit of a straw man in these discussions. He is presented as maintaining that psychotic experience, and in particular delusion, is un-understandable. Frith and Johnstone (2003) quote Jaspers

The profoundest difference . . . seems to exist between that type of psychic life which we can intuit and understand and that type which, in its own way, is not understandable and which is truly distorted and schizophrenic . . . [We] cannot empathize, we cannot make them immediately understandable, although we try to grasp them somehow from the outside.

George Graham (2010) says,

If Jaspers is right then the utterances of classiﬁed schizophrenics, or of individuals with stark or severe delusions often are so alien and bizarre that they ultimately defy empathic understanding . . .We may say of such people “It’s not as if she really believes that Obama’s thoughts are being inserted into her mind” or “It’s not as if he actually thinks that his wife has been replaced by an imposter”.

Frith takes Jaspers to be suggesting that we cannot understand schizophrenic psychosis at all. Actually, Jaspers is talking about empathy rather than a scientific understanding. Frith’s theories about the origin of schizophrenic positive symptoms aren’t really about this type of understanding at all. In general, however, Jaspers is portrayed as promoting an organic view of psychiatry and minimising the psychological. Jaspers was a phenomenologist and this, ironically, meant for him that he was trying to understand and describe clients’ experience in their own words. Objective, descriptive psychiatry was no substitute for the clients’ own descriptions, he argued, quite surprisingly considering how he has been later portrayed. He is unfortunate in the followers he later attracted, possibly. He claims that the reports of psychotics are shown to be reliable by the similarity of the reports of different clients. We would take thought insertion to be nonsense if it wasn’t that lots of different clients independently say the same thing. Jaspers made a distinction between “delusion-like ideas” and delusions proper. Delusion-like ideas are what we regard as delusional beliefs in which we can understand the reaction of the person in some way. For example, if a person is hearing voices and believes that there are ghosts in his room or that a radio has been placed in the ceiling of his room, these are understandable beliefs secondary to other psychotic experiences. Or if someone breaks down after a loss or a great shock and begins to develop delusions of persecution or guilt, we can understand this as an emotional response. We can understand the deduction that there is or might be a Philosophical psychology 57 radio in the ceiling as a deduction. Delusions proper are not derived in this way. He says that there are three possible theories: 1) that delusions proper do not exist and that all delusions are what he calls delusion-like ideas, 2) that delusions result from faulty reasoning, and 3) that delusions proper arise from a process that we cannot empathise with. He dismisses the first two hypotheses because, in the case of the second, clearly very intelligent people can become delusional and, in the case of the first, if a person goes on believing that a voice is that of their boss who is invis- ibly present in the face of all other evidence of their perceptions and knowledge of life there must be some other factor involved. A client of mine believed that there were sharks in the water in her shower, although she was well aware that sharks are too big to come through the shower head and that she had never been bitten. She was, in my estimation, of above average intelligence. How are we to explain this? Jaspers argues that normal perception is always suffused with meaning. Heidegger talks of our interaction with the world as being-in-the-world and that we do not begin as observers of what we perceive but that our original position is always of our relationship to objects. By this he means that we don’t perceive things in a neutral, passive way but from the beginning always in relation to our needs and actions. It is a mistake of the academic to imagine that we are in relation to the world as disembodied observers, Descartes-like wondering whether we exist, rather than from the beginning in relation to the world in terms of actors. An example from Jaspers is that when we perceive a knife we see it as a tool. So that our perception is filled with meaning and by this he means the uses with which we can put the knife to use. This automatic perception of objects in relation to their use or function in our lives is changed for the person with delusions proper. Jaspers gives the following example:

In the afternoon the sun did not seem to be shining when my thoughts were bad but came back when my thoughts were good. Then I thought that cars were going the wrong way; when a car passed me I did not hear it. I thought that there must be rubber underneath; large lorries did not rattle along anymore; as soon as a car approached, I seemed to send out something that brought it to a halt . . . I referred everything to myself as if it were made for me.

So, Jaspers thought that some delusions (in his terms “delusion-like ideas”) were clearly related to either “evidence” or emotionally disturbing events. So in these cases he is in agreement with Maher (or rather Maher is in agreement with Jaspers). With delusions proper Jaspers says that although there is a changed phenomenology one can make some attempt at understanding. The person who is developing a delusion often begins with the feeling that something has changed; a sense that something uncanny is happening. One can imagine a feeling of unfamiliarity or oddness. This produces a state of terror in the person who is undergoing the psychosis. The person searches for an explanation of this change and once the explanation is settled on (either a persecutory or a grandiose explanation) this is anxiety reducing. And this cements the person to the delusional account of what is happening. This account is 58 Part one difficult to distinguish from Maher’s account of the development of delusions. It is far more about the reasons of the person for holding the delusion than the theories of Frith or Hoffman (operating as they do at the sub-personal level). He describes certain psychotic symptoms as outside of our experience and therefore impossible to understand empathically; for example, when clients tell us that thoughts have been inserted into their mind, or withdrawn from their mind. The terminology, he says, comes from the clients themselves, but it seems impossible to understand it. As well as thought insertion he also describes “made” feelings, in which a client feels that certain feelings have been produced in them by an outside force. I had a client who said that he couldn’t do things around the house because he was controlled, and wasn’t allowed to do certain domestic duties, because if he did people would be harmed. He meant that there was an agency of some kind which controlled him. He spoke of “The control”. He didn’t hear a voice telling him these things, and it wasn’t his conscience, as it might be in an obsessional patient. Jaspers described other disturbances of the self. These are not to be found prominently in describing the symptoms of “schizophrenia”, but this is because of the move to create reliability in the diagnosis of “schizophrenia”, hence the emphasis on symptoms which can be clearly identified, and changes in the sense of self may be less easy to agree on than the report of hearing voices or a persecutory delusion. Other subtle changes can occur. These are examples of delusional significance and delusional reference.

Then there was a dog that seemed hypnotised, a kind of mechanical dog made of rubber. There were such a lot of people walking about, something must be starting up against the patient. All the umbrellas were rattling as if some apparatus were hidden in them . . . patients have noticed transﬁgured faces, unusual beauty, of landscape, brilliant golden hair, overpowering glory of sunlight. Something must be going on. The world is changing a new era is starting.

Jaspers maintains that there is a change here, not in interpretations of perceptions but a change in the direct perception of meaning. Direct perception of meaning is opposed to the British Empiricist (and therefore the CBT) view that our perceptions of the world and our interpretation of it are separate. However, direct perception of meaning does seem to be a fact. When we see a fork we see an instrument for eating with. We can say that this direct perception relies on an underlying process of some deductive type, but this is a hypothesis and not part of our observed phenomenology. We just see the fork as something to eat with. He excluded people with some diagnoses; however, on the basis that part of the problem that they had was unreliability or untruthfulness (he meant severe personality disorders). He describes a number of subtle changes in psychosis which these days are not usually noticed. They are not usually noticed because interviewing of clients is directed towards identifying certain key symptoms (“Have you been hearing voices when no one is around recently?” “Does there seem to be some sort of conspiracy going on at the moment?”). Philosophical psychology 59

Recently there has been a rebirth in the interest in the phenomenology of “schizophrenia” and psychosis. Parnas and Sass (2003) suggest that there are fundamental changes in the phenomenology of the person with “schizophrenia” and that these changes underlie the manifest symptoms of “schizophrenia”. This is a rebirth of the idea of a changed phenomenology, because behavioural psychology had led psychologists to believe that the only scientific psychology would be one that focussed on observable behavioural phenomenon and, more importantly but as part of the same empiricist trend, the increasing tendency of psychiatry to want biological models. Also the development of the DSM and ICD 10 systems which stress empirical criteria for diagnosis has meant that symptoms that are more clearly defined empirically have been the subject of investigation. It is easier to define hearing voices than it is to define a change in one’s perception of one’s self. Parnas and Sass have suggested that the person with “schizophrenia” suffers from a change in the perception of the self (an ipseity disorder) and that these changes can explain the positive and negative symptoms of “schizophrenia”. Parnas suggests that the negative symptoms of “schizophrenia” seen in this light become positive symptoms; for example, the absence of a usual sense of self. This raises questions that we have seen arise in the philosophy of mind. Hume says that when he looks for which of his perceptions is the perception of his “self” there is no such perception, so that the concept is meaningless. His problem comes from trying to identify the idea of self without reference to the body. However, although it may be true that usually we do make use of bodily criteria in identifying different subjects of states of mind, it is also true that we have an idea of ourselves as separate from our idea of ourselves as a body, albeit that this concept is logically dependent on our concept of ourselves as a body. This is one of the reasons that thought insertion has interested philosophers. An important distinction needs to be made between what is logically possible and what may seem to make sense to us. Language contains powerful metaphors which lead us into misleading forms of speech or ways of thinking. This is the idea of the “self as soul”. People talk of themselves as separable from their bodies and also it is a matter of empirical fact that people talk of experiencing themselves as changed, or altered. Direct perception seems to be in line with our day-to-day experience. The reason why we may struggle against this idea is that it seems to run counter to a certain theory we have of the world (the empiricist idea of knowledge as being derived from experience and the experience being of an objective world). Hume expressed this with his theory of impressions and ideas. All thinking is a quasi-perceptual after- effect of sensation, because all real knowledge must be based on experience. If it wasn’t based on experience how could it be knowledge? This model still holds much influence today. Heidegger thought perception of the world was direct, rather than derived. Jaspers was influenced by this approach. Starting from the position that we have direct perception of meaning he argues that this is what has changed in psychosis, and in particular in delusions. So for him delusions proper are not a conclusion (as they are in Maher’s theory) but they are more an experience, and an experience 60 Part one that includes a direct experience of meaning. He carried out a series of qualitative explorations of the experience of psychotic people. Some of his conclusions have become the bread and butter of modern-day psychiatry, but some of the experiences he notes have been overlooked to a large degree in the contemporary literature. Although he is often quoted as defining a delusion as being held with extraordinary conviction and as impervious to evidence and counter-argument, and also as impossible, he says these criteria tell us nothing of the psychological nature of delusions and are essentially vague. He suggests that if we go beyond these merely external characteristics we can distinguish the “original experience from the judgment based on it”. As mentioned above, there are two groups of delusion: one group emerges understandably from shattering experiences which provoke guilt or other strong emotions or from hallucinations or other false perceptions; the second group (which he regards as real delusion) is psychologically irreducible. He argues that the origins of proper delusions are in a phenomenological change. These changes include what he describes as “delusional atmosphere”;

The environment is different somehow – not to a gross degree – perception is unaltered in itself but there is some change which envelopes everything in a subtle, pervasive and uncertain light. Something seems in the air which the patient cannot account for; a distrustful, uncomfortable, uncanny tension invades him. ( Jaspers, op. cit.)

Finding a solution to the cause of this (in a delusional explanation) brings relief. He suggests this is the same relief that we feel when we hit on an explanation for feeling depressed or anxious (whether we are right about the cause or not). As well as this explanation of the formation of delusions (which doesn’t seem very different from the explanation offered by Maher or others as a cognitive explanation; rather, it seems verbally different), Jaspers suggests that there is a change in the meaning of experiences (this being a direct experience of meaning). He suggests that the experience of the psychotic person offers a world of new meanings. Meaning can be perceived directly by seeing or hearing or be directly present in the imagination. Jaspers suggests that Heidegger’s (1962) insight is relevant here. When we see people in the street we see them moving about pursuing their various purposes; when we see a house we see it as there for people to inhabit; and when we see a knife we see an implement to use for cutting. It is this type of experience that can be changed in psychosis. The psychotic experience of delusion is based on changed immediate perceptions of the environment. The person is in a “world of new meanings”. The person knows that something strange is afoot. Any experience can be suffused with changed meaning in this way. This is what he means when he goes on to describe speciﬁc categories of delusional perception, delusional memory and delusional ideas. They are simply examples of the primary experience of changed meaning. The person may see people in the street in uniform and it means that there is a world war. A woman sees a man on the street and knows immediately that Philosophical psychology 61 he is her old lover, despite him looking completely different. Or the person will get a sense that the world is eerie or horrifying or mysterious and wonderful – full of signiﬁcance – without any clear change in what is seen or heard. Delusions of reference are simply another version of the same experience but in this case the meaning of the changed meaning is clearer. Sometimes the person takes a real coincidence as meaningful but at other times a comment is taken as having a completely different meaning, which the client knows is about them. Jaspers gives the following example:

. . . the customers were looking at me oddly too as if they had guessed something of my suicidal thoughts . . . as I went across the square the clock was suddenly upside down; it had stopped upside down. I thought it was working on the other side; just then I thought the world was going to end; on the last day everything stops; then I saw a lot of soldiers on the street; when I came close one always moved away; ah, I thought, they are going to make a report; they know you are a ‘wanted’ person . . . In the afternoon the sun did not seem to be shining when my thoughts were bad but came back when they were good. . . . At the police station I had the impression that I wasn’t at the station but in the Other World; one ofﬁcial looked like death himself. I thought he was dead and had to write on his typewriter until he had expiated his sins. Every time the bell rang I believed that they were fetching away someone whose lifetime had ended. . . . it was on a stage, and marionettes are not human. I thought they were mere empty skins . . . I thought everyone was bewitched . . . I felt I was brightly illuminated and visible when others were not.

In this example it is clear that there has been a transformation in the way that the person is experiencing the world. Without any change in perception the world is transformed by the transformation of the directly perceived meanings. Her direct perceptions of the world are suffused with sinister meaning. She has the impression that she is in the next world; she doesn’t conclude this as a deduction. Why does she think that he has to type on a typewriter to expiate his sins? This isn’t a mistaken conclusion or a rational deduction. It reminds one of the associative thinking of a dream and one gets the impression her experience expresses her feelings rather than causes them. One man I worked with told me that when he first became psychotic everything was full of meaning. He would look at any object and it would have a hidden meaning. He said that he lived in “a different world”. He was functioning well when I met him many years later but he would still see a piece of graffiti on the street and know it was a message for him. It was not that he saw the graffiti and deduced that it was a message for him. His understanding of this came with his seeing the graffiti. The suggestion that this must be an inference comes from our assumptions. Another man with “schizophrenia”, Harry, told me that he saw visions and heard voices. He saw the apparition of his dead wife, who would come and follow him. He also heard several voices. These voices put him down and criticised him. They told him that he should kill himself and that he didn’t deserve to live. One voice 62 Part one was that of his dead wife. But there were other voices which he could differentiate by the sensory quality of the voice. They didn’t talk at the same time but he identified them as separate. He also experienced the television talking to him. But this was more that he would experience the people on TV as communicating with him telepathically rather than speaking directly to him. He said that the lips of the people on TV didn’t move and it was more of a telepathic communication. These experiences happened more in the evening and more when he was unhappy but they could happen at any time. He told me that when he used the microwave it would talk to him. I asked him to explain how and he said that he would see words on the microwave telling him to kill himself or that he was useless. He went on to say that he believed that the microwave was alive. He said that he believed that all electrical machines were alive. He also believed that he was from Mars. He believed he was from Mars because he heard the voices of aliens. I thought that many of his psychotic experiences could be linked to his unhappy and neglected childhood. He had been sexually abused by an older brother. His father had been ceaselessly critical of him as had his mother and he felt that no one cared about him. He had a divided way of thinking about his psychotic experiences. On the one hand, he believed them and there was no “as if” about any of these experiences; on the other hand, people had told him over many years that these experiences were delusions and hallucinations and that they were an illness due to an imbalance of dopamine, and he also believed this. In casual conversation with him you would not be aware of any of these experiences or beliefs. He could carry on a perfectly good conversation about his life or treatment or any other topic; for example, the state of the world or the qualities of the various doctors, nurses and other care providers that he came across. He had a good sense of humour. Was his belief that electrical machines were alive an interpretation based on a sense experience or a direct perception of a changed meaning? It obviously wasn’t a deliberate deduction based on the evidence. If we give up that idea then what would the difference be between an automatic interpretation and a direct perception of changed meaning? In “On Certainty” Wittgenstein (1969) maintains that there are certain propositions which we simply take for granted, such as “The Earth has existed for a long time before I was born”. He argues that in a case like this, the “bedrock”, the idea of doubt, cannot take hold. We can’t say we know these propositions, because we can’t make sense of what it would be like to doubt them. Some propositions about the world are the background to our understanding. Rhodes and Gipps have suggested that changes in this background may explain the bizarreness of delusional beliefs. This seems to be a version of Jaspers’ idea of a changed phenomenology in psychosis (Searle, 1994; Rhodes and Gipps, 2011). Thought insertion is one of these experiences (that someone else’s thoughts are inserted into my mind). This is the type of experience of which he means that there is a gulf between normal experience and psychotic experience. He describes other alterations in the self, some taken from clients with a diagnosis of “schizophrenia” but also some taken from experiences with hashish and mescaline. At this time the hypothesis that hallucinogenic drugs might help to isolate the underlying organic Philosophical psychology 63 cause of psychosis was certainly taken seriously, but Jaspers was interested in documenting the phenomenology of psychosis apart from that particular conjecture. Hallucinogenic drugs certainly produce a psychosis of some kind, even if it differs in many ways from schizophrenic psychosis. In addition to describing thought insertion there is thought extraction (someone is taking thoughts out of my mind), thought broadcast (my thoughts are being sent out to other people so that they can read them) and loud thoughts (thoughts being spoken so that they can be heard). He also describes clients who experience themselves as identified with an external object: “I am that apple”. Clients also describe having more than one personality. Traditionally psychiatry has tried to distinguish between dissociative and psychotic forms of this type of experience. Carl Jung (1935) was asked about the difference between the dissociative and psychotic types of splitting and he described the difference as a matter of degree rather than of kind. Contemporary accounts tend to assume that dissociative reactions are of a different kind in some way. So in this vein psychiatrists describe the verbal hallucinations of clients with personality disorders as pseudo-hallucinations and the verbal hallucinations of psychotic clients as true hallucinations. But often it seems that the diagnosis affects the classification of the hallucination rather than the other way around. Tim had a diagnosis of borderline personality disorder of a quite severe type. He had been sexually abused by his next-door neighbour in a number of particularly degrading ways. His family fell apart and his problems became known throughout the town. He was severely neglected and at times didn’t have enough to eat. As well as being victimised in a sadistic way by his neighbour, he also had to deal with the shame of seeing him exposed and denigrated. When he eventually left home he moved in with a man who was violent towards him. After several years he left him and is was at this point that he broke down. He reported visual hallucinations which he believed were real (he saw groups of hooded figures in his garden at dusk, and believed that they were planning to assault him); he also heard voices which spoke to him and which he was certain were real. These hallucinations did not seem different in any way to those of someone with “schizophrenia”. Labelling them as pseudo-hallucinations seems to be a result of the other information, the prominence of trauma and the other dissociative symptoms that he had. Changes in the experience of the self seem to be outside of the normal range of experience. Or if people in the general population do have these experiences they don’t have them much, because if you had these experiences much of the time you would be unable to cope. One way of characterising these experiences is that they involve the breakdown of boundaries of the self. What is really puzzling about saying that I have someone else’s thoughts in my mind? Well there is a way in which, of course, this is not at all puzzling. Someone may have suggested to us that, for example, a friend is disloyal and, although we don’t really believe this, we may find that a seed has been sown and that we keep thinking about this. We might then say that someone had put that idea in our mind. But here we mean the content of the thought has been put into our mind, not that someone else is doing the thinking in our mind. And the experience of thought insertion is, of course, that 64 Part one someone else is doing the thinking in one’s mind. It is this idea that is difficult to make sense of, because if we ask which idea someone was thinking in your mind the only way of identifying the idea is by reference to the idea that I thought. One would be tempted to argue that this was just nonsense if it wasn’t for the fact that clients independently report the same experience. The way in which we individuate thoughts (distinguish between same thought as in same content, i.e. qualitative identity, and same thought as in identical thought, i.e. numerical identity, is by who the thought occurs to). Wittgenstein (1953, 1975) points out that one could experience a pain in someone else’s hand (if injury to someone else’s hand produced pain) but it would still be my pain. He therefore concluded that this sense of ownership was an illusion of language (see the discussion by Strawson below). Here it seems that one thing that makes this difficult to think about is the metaphor lying behind the way in which we speak about thinking. Lakoff and Johnson (1980) have suggested that much of our language operates on underlying metaphor. Following Reddy (1979) they suggest that in thinking about language we are influenced by the metaphors that: 1) ideas are objects, 2) linguistic expressions are containers, and 3) communication is sending. And there is the related metaphor of the mind as a container. This metaphor, which lies behind the way we talk about thoughts and ideas, makes it easy for us to think that an idea is a transferrable object which happens to be in one container (one mind) but could be in another. This is part of Wittgenstein’s point that it is meaningless to ascribe states of mind to a stone. We cannot say if a stone is or is not in pain because it is not clear what it could possibly mean. Ascription of states of mind makes sense when we ascribe them to people or animals. The same metaphor lies behind the idea of the boundaries of the self, i.e. the self is an area or place and thoughts and experiences are contained with the boundary or area of that place. This runs counter to the way we actually identify and re-identify thoughts, ideas and experiences. Obviously these underlying ideas are metaphorical, but it can be hard for us to grasp this. This makes the idea of passivity with regard to one’s own thoughts or feelings even more incomprehensible. But are these ideas quite so incomprehensible to us? Is there really such a gulf between our way of thinking and that of the person with these psychotic experiences? What of the ideas of mediumship and automatic writing and demonic possession? Someone says, “I am not the person sitting in the chair talking I am making them say these things”. Here we might say, following Wittgenstein (1958), that whether this makes sense may depend on whether we can find a use for this way of speaking. He imagines a situation in which a person has a different character and set of memories on odd and even days of the week (as mentioned above). On the odd days he can only remember the experiences of the odd days and on the even days he can only remember the experiences of the even days. He says . . .

Are we bound to say that here two persons are inhabiting the same body? That is, is it right to say that there are and wrong to say that there aren’t, or vice versa? Neither. For the ordinary use of the word “person” is what one might call a composite use suitable under the ordinary circumstances. If we Philosophical psychology 65

assume, as I do, that these circumstances are changed the application of the term “person” or “persons” has thereby changed.

This linguistic turn is helpful in rooting the discussions about self and self-hood in the real context in which we use these concepts. From this perspective the descriptions of these types of psychosis seem to be operating outside of the normal language game of identifying and talking about persons. It is an example of not playing the game-non-conformity. Obviously the psychotic person isn’t choosing this stance. But if we focus on language as it is actually used, we identify our mental states and others’ mental states on the basis of the social interactions we are involved in with the other people. Standing back and reﬂecting on our states of mind in an introspective way is not the usual way in which we use these words or identify mental states. The use of a word depends on its role in a language-game and if the circumstances around the language-game change then the use of the word changes. But clearly there is a difference between the person who has a transformed experience of the meaning of the world on occasion and the person who is lost in the type of experience Jaspers describes. In this case a difference in quantity may become a difference in kind.

Philosophical aspects of Frith on thought insertion Frith’s account of these experiences explains them on a sub-personal level. His model, as discussed in Chapter 4, explains these experiences as due to a deficit in self- monitoring, a difficulty in metarepresentation. In a way, this is a type of Maherian explanation. The person asserts that his or her thoughts are not his or her thoughts because of a changed capacity to self-monitor his or her intentions. This account seems to raise some conceptual problems; it seems unclear on what basis I could be distinguishing my thoughts from others’ thoughts, given that I am never going to be in the position to directly experience others’ thoughts in the way that I perceive my thoughts. It can be argued that this is in danger of an infinite regress where the apparent explanation depends on a homunculus, and this is no explanation at all, because it could be asked how we know that the homunculus is having our thoughts. Probably the best defence of a Frith-like position comes from John Campbell (1999, 2002, 2004). One question about Frith’s account is whether it makes sense to think of thinking as a motor action. Feinberg had suggested that a mechanism of checking actions was self-initiated by a comparator which compared the intended action to the action that was executed. So if I intend to raise a glass I compare the intended action with the action as executed. This feedback allows me to correct my actions if they are incorrectly executed. So if I intend to raise the glass but actually I move it downwards, the feedback will allow me to correct this act. Feinberg (1978) applied this to intentions and thoughts. He suggested that the purpose of this self-monitoring was to keep thoughts in line with the intended stream of thought. This, however, does seem to be in danger of an infinite regress. A sub-personal process needs to have a knowledge of what my intention is in order to determine 66 Part one if it is my intention. This seems different to the situation with movements. Also it is clearly not the case that we deliberately intend to think all our thoughts. If I had to deliberately intend to think I would like to go for a walk, then I would have to deliberately intend to intend to think I would like to go for a walk. Campbell argues that if there were an executive agency which planned our thinking as a motor process the schizophrenic perception that his or her thoughts were being controlled by someone else would as a matter of fact be quite near the truth rather than a delusion. We think of our thinking as the primary executive process, rather than being determined by some other process. Campbell suggests that this account can be rescued by having the comparator process not available to awareness. He also suggests that it is important not to do violence to our understanding of our thoughts as caused by our beliefs and our goals. Generally if we are thinking of going to the shops to buy milk we see this as caused by a combination of wanting some milk and believing that if I go to the shops I will be able to buy some milk. He suggests that there need not be a contradiction between these two explanations. There is a process by which the beliefs and desires produce a thought about going for a walk. He argues that the background desires and beliefs cause a motor process which results in the thought that I want to go for a walk. The point of the motor instruction is to leave room for the disparity between intended thought and actual thought, which results in the lack of a sense of ownership of the thought. This is an account in which two features of normal experience of our mental states come apart. Usually there is the experience of having the thought and the experience or rather the feeling of producing the thought and this comes apart. He argues that usually we think of thinking as the primary executive feature. Campbell argues that it is hard to take seriously the idea that there is something else in one’s mind or brain that is making the executive decision for us. In this, his account is not bottom up in the way that Frith’s account is. So he goes on to argue that our previous occurent thoughts count as part of the causes of our current thoughts and that there is interplay between our beliefs and our thoughts. Our conscious thoughts are caused by our beliefs and desires, but beliefs and desires can also be caused by our deliberations (conscious thinking). This is different to the bottom-up homunculus- based theory of Frith. When central monitoring goes wrong we become aware of the discrepancy between our desires and our beliefs and our thoughts. We suffer from self-alienation, which leads to believing that our thinking is under the control of an alien force. Campbell accepts that as an account of our ordinary knowledge of our own thoughts it is implausible that we are aware of our intentions to think our thoughts. This would suggest that we are always aware of both what we think and the planned “efferent copy” of what we intended to think. So he rejects that part of the account of Feinberg (and also of Frith). He suggests that we are only aware of the thought that we are having and that the match between the efferent copy and the actual thought occurs out of awareness. The hypothesis that thought may be experienced as alien because it does not match a prior intention can lead to an infinite regress. If I have an intention to think “It is raining”, which is understood as containing the meaning of the statement Philosophical psychology 67

“It is raining”, do I need a prior intention to have had that intention? This is obviously absurd. Campbell has argued that to attribute this degree of meaning to a sub- personal process just seems very unlikely (Hacker (2003) would argue that it is meaningless and Searle (1992) has argued that the very idea of unconscious processes that could not in principle be made conscious is incoherent). Campbell suggests that if the purpose of the process is to keep the thoughts on track, there must be a high degree of planning in the intended efferent copy. Campbell proposes a variant of the comparator hypothesis. He suggests that the comparator compares the “occurent thought” not with a prior intention to think that thought but with the person’s desires and goals. If the occurent thought does not match the person’s desires and goals it is perceived as alien. This version of the comparator hypothesis is different from Frith’s hypothesis in a number of ways. One striking difference is that the comparison process can go both ways. I can compare my occurent thought with my desires and beliefs and decide that the thought does not fit with my beliefs and thoughts and adjust the thought, but also I may keep having a thought and decide that my beliefs and goals do not fit with my thoughts and realise that my beliefs and goals are not what I thought. Frith’s model is very much a bottom-up model where the more basic processes cause the higher processes. Information is processed at a lower level, which results in higher-level process. But, as Campbell points out, this seems to locate executive functioning outside of consciousness and sets up an agency in the brain or mind which is monitoring and guiding the process of conscious thought. Campbell suggests that on this model of the mind the psychotic perception of thought insertion as thoughts inserted into the mind by an alien agency is not far from the truth. Campbell’s model is rather that thoughts and beliefs perform this function. In the usual case my thoughts more or less reflect my beliefs and goals and vice versa. But again not all our thoughts do reflect our goals, as pointed out by Hoffman. In “The First Person, Embodiment, and the Certainty that one Exists” (2004) he suggests that the comparator model can explain our sense of identity. It has been argued that Descartes’ Cogito establishes less than he believed, in that establishing that I exist as the same person across time does not follow from the inability to doubt that one exists at a particular moment. But the concept of myself seems to involve being able to integrate experiences at different times. He argues that our concept of our self leaves it open as to what kind of thing we are. Shoemaker had argued that our sense of embodiment depended on the empirical relationship between our “volitions” and our actions, i.e. the movements of a particular body and our sense experiences and the sense organs of a particular body, so that we experience ourselves as embodied because of these empirical relationships. Campbell suggests that the attempt to understand which body we are linked to is based on sub-personal mechanisms; the action of Frith’s “comparator”. The comparator mechanism which allows us to distinguish our movements from movements of our body which are not actions, which just happen to us, does this by comparing the motor instructions for action to the action as carried out. These comparisons are made outside of conscious awareness, but the results of these comparisons are what our sense of agency is produced by. He contrasts the implicit, unreflective knowledge we have that we 68 Part one are causing certain movements in our body and the self-awareness when we form ideas explicitly, such as “I broke the cup”, when an idea of ourselves enters the picture. However, the initial sense of ourselves as the cause of certain actions, outside of conscious awareness, is the basis for the self-reflective awareness of ourselves in judgements that we are the agent of certain actions. And these judgements are the basis of our sense of personal identity. He argues that the comparator model can explicate the fact that when we use the word “I” we can refer without the possibility of error to something which we cannot identify in another way. He argues that the objection to this, that it seems incoherent that one’s thoughts should be planned prior to them being had, is that thoughts have to be caused and ordered by some process, otherwise thoughts would be chaotic rather than ordered, much as someone with thought disorder. The comparator links your long-standing beliefs and memories to your current stream of consciousness. It is not clear how this account can make sense of the random thoughts that we have, however. So some of our thoughts are orderly and connected to our desires and goals. But this is not all of our thinking. I may, in daydreaming or in free association, generate a whole series of thoughts which are not connected to any particular beliefs or plans or goals. Obsessional thoughts are a limiting case in which the thoughts we have are thoughts which we disavow and do not intend to think but which we do not disavow as our thoughts. There is also something circular about this way of arguing. After all, if the part of the brain that generates the motor plan for thoughts is able to do this without a prior motor plan, why should overt thinking need it? A powerful metaphor for our knowledge of our thoughts, images, daydreams or sensations is that of the inner eye, so that introspection is thought of as a type of inner seeing. But this may not be the appropriate model for thinking about our knowledge of our mental life. I know all sorts of things about myself; for example, I can tell what my beliefs are without an act of perceiving. For example, I know that I believe that I am 5’ 10” tall. But there is no mental process that I am aware of that determines this, so if one wants a psychological account of this one has to look for a sub-personal mechanism. But if this sub-personal process involves this belief being represented somewhere in my brain then I am in danger of generating an infinite regress. An alternative account might be that the ability to integrate these various facets of personal identity might be a power of the brain. There is a danger in these accounts of psychosis that the explanation can result in the person seeming too rational. After all, if the mechanism which allows us to check our thoughts are our thoughts was not functioning, then it would seem that the delusion of thought insertion would be an understandable deduction from an unusual experience, in a very Maherian type of explanation. Campbell interestingly suggests that if the ability to experience the link between our beliefs and memories and our current thoughts were to be lost (by the malfunctioning of the comparator), then the sense of being a person would collapse; the loss of the sense of identity would ensue. He quotes Gerrans, who suggests that the delusion of being dead follows from the experience of deep depression. The lack of Philosophical psychology 69 emotional connection to the world is responsible for the belief that one is dead. This is an interesting suggestion, but surely this involves some metaphorical sense of being dead, rather than the usual meaning of the term. After all, if I wanted to know if someone else was alive I would have no need of an investigation into their sense of vitality to determine this, and the same criteria obviously apply to myself. It seems as if the idea of having criteria for knowing if I were alive is a self-defeating activity. The loss of the distinction between my thoughts and other people’s thoughts is not the only or most common lack of connection in psychosis, however. One feature of all delusions is that the client stands in a particular relationship to the rest of the world. People who have persecutory delusions see themselves at the centre of a conspiracy; people with delusions of grandeur see themselves as of high status; people with delusions of erotomainia see themselves as loved by a famous person. And this is also true of people who have delusions of thought insertion or broadcast, or “made” feelings. People do not have delusions that their next door neighbour or someone at work is the centre of this changed world. It seems possible that this reflects some change in the person’s relationship to the world, but this change may not be explicable in terms of a lack of ability to identify one’s own thoughts. The delusion of thought insertion could as easily be described as a lack of ability to correctly identify others’ mental states as one’s own. Actually, the problem seems to be better characterised as the inability to distinguish between one’s own and others’ mental states rather than incorrectly identifying one’s own mental states. It is not that I experience my thoughts as not belonging to me, but that I experience my thoughts as those of someone else.

Imagination and delusion An alternative approach has been suggested by the philosophers Gregory Currie and Ian Ravenscroft (2011) (also Currie, 2002) and Colin McGinn (2006), who have (separately) suggested that psychosis does not reflect a problem with “the belief system”. Delusions are not caused by a mistake in interpreting evidence. They suggest that delusions instead are caused by a difficulty in distinguishing between imagination and belief. McGinn suggests that the psychotic client experiences strong imagery associated with an emotional experience, and that this imagery is then mistaken for reality. McGinn points out, following Wittgenstein and Sartre, that imagery is not a weak form of perception. Imagery differs from perception in a number of ways. Imagery is typically under voluntary control, whereas perception obviously is not. We do not have to compare our images to a picture of something in order to determine what the image is of. Also, we don’t form beliefs on the basis of our imagery, whereas we do form beliefs on the basis of our perceptions. If I visualise a table I am not going to believe that there is a table on the basis of my imagery. If I see a table I will (visual illusions and hallucinations excepted) believe that there is a table in front of me. McGinn argues that dreams are a type of imagery rather than a type of perception. Dreams are a story told in images. But why do 70 Part one dreams lead to states of belief when imagery usually doesn’t? This is an issue for him, because he argues that dreams are not a type of perception. If dreams were a type of perception this issue would not arise. He suggests that this implies a split between the teller of the story and the receiver of the story. Dreams, to a greater or lesser degree, have the form of a narrative. But as we cannot coherently be said to be telling ourselves a story and believing it, this implies that there is a separation between teller and receiver in the mind. To be convinced that the story is true I cannot be telling myself the story. McGinn suggests that delusions are to be understood in a similar way to dreams. Dreams are a form of imagination in which a person is told a story in images. (Or tells him- or herself a story in images, with the proviso that they don’t know that they are doing this at the time.) Delusions or psychosis are not, he suggests, based on misperception but rather are an example of unrecognised imagining. He suggests that delusions might develop in the following way. The person is subjected to an emotional shock or a crisis. Strong emotion generates imagery associated with the emotion. The person does not recognise the imagery as being produced by the imagination but takes it for reality. So, for example, Bill is in conflict with his criminal contacts, because he refuses to go along with what they have asked him to do. He gets anxious because of this conflict and his anxiety generates auditory imagery of people wanting to harm him. However, he doesn’t recognise this as auditory imagery but takes it for voices he is hearing, which terrifies him all the more. Or it might be that the person experiences imagina- tive sensing in which the person imaginatively projects a malevolent meaning on an innocent conversation. This is based on the experience of seeing something as something else, as, for example, in the case of ambiguous diagrams. It is a changed meaning of a perception. Of course, why he doesn’t recognise his imagery as imagery is the question here. If one thinks of imagery as a type of perception, then one might imagine that this is to be understood simply as a perceptual error. Maybe the imagery is very vivid. But McGinn points out that imagery differs from perception in the ways described above. Currie also suggests that delusions originate with the inability to distinguish imagination from reality. He suggests a form of Frith’s hypothesis, but related to imagination not perception. Clients who are deluded are unable to distinguish what is real from what they imagine because of the efference copy/corollary discharge mismatch. But we have seen earlier how this model leads to paradox. Do I really know that I am imagining something by comparing what I am thinking to what I intended to think? To be unable to distinguish what one is imagining from what one is perceiving doesn’t seem likely to be a matter of quasi-perception. Being anxious and having the thought that someone is following me can merge into believing that someone is following me. But to believe that I am the King of England doesn’t seem to emerge from feeling overly optimistic. To believe that other people are putting thoughts into my head doesn’t seem to be an extension of feeling intruded upon by others. The psychotic person, then, does not wrongly conclude that they are Napoleon but they imagine that they are Napoleon and then fail to realise that they are imagining this. To imagine something and not realise that one is imagining it is, Philosophical psychology 71 however, clearly a drastically changed state of mind that needs some further explanation. These suggestions are particularly helpful, because they show us that our other accounts are influenced by the idea that the brain or the mind can be thought of as primarily, as an information-processing machine. In imagination and storytelling, information processing is not the central process. This hypothesis could lead to a different series of questions to the information-processing error hypothesis. Bernard Williams (2006) in “Imagination and the Self” discusses the relationship between imagery and imagination. He makes the distinction between visualising something and imagining it. One way of imaging that I am the King of England is to form an image of myself with a crown and surrounded by the court retinue. However, this image is not me imagining myself as the King of England without what he calls an accompanying narration. After all, I could have the same image and it might be because I am thinking that someone who was my twin was the King of England. I might say that I was imagining that I was the King of England and it would not be evidence against this that the image was too indistinct or didn’t really bear much resemblance to me (maybe I don’t have a very good idea about what I look like). These ideas are very useful, because they illustrate an alternative approach to delusion. The information-processing model seems plausible to us if we are impressed with the computer as a model for the mind. The hypothesis that it is the boundary between the imagination and objective ways of thinking that is changed in psychosis makes some of the experiences of psychosis much easier to understand; in particular, perceiving the world as being linked to our goals and memories. McGinn’s idea of dreams and delusions as stories we tell ourselves without realising it certainly deserves further thought, as it has considerable implications.

Stephens and Graham Stephens and Graham (2000) in their book “When Self-Consciousness Breaks” argue that the apparent paradoxes involved in the idea of self-monitoring thoughts can be avoided. They argue from a phenomenological point of view. Cases of thought insertion, they suggest, show something about the nature of our normal experience of our thinking. People who experience alien thoughts are not making an error of mistaking thoughts in their mind for thoughts in someone else’s mind, rather there is a sense of our thoughts as being in our mind, but there is also a sense of our thoughts as our actions, and it is the sense of our thoughts as not being our actions which is changed in people that have this experience. Stephens and Graham argue that the apparently puzzling or paradoxical nature of thought insertion is not really so puzzling or paradoxical. One account of the experiences of thought insertion is that the person misidentifies their thoughts as those of someone else due to a fault in perception. On this account the experience of one’s own thoughts changes so that one is aware of the thought but unaware of the sense of the thought belonging to oneself. So thought insertion is a type of changed experience. They describe this as the “loss of ego boundaries” explanation of thought 72 Part one insertion. This hypothesis can seem difficult to understand. How can I be aware of a thought and not aware that it is my thought? Stephens and Graham argue for a different account of thought insertion. They suggest that the experience of thought insertion is not a change in the perception of thoughts but rather is due to a change in the experience of having caused the thought. Just as my body may move without me moving it (say my arm goes up without me raising my arm), I may have thoughts which I do not have the experience of causing and therefore do not seem like my thoughts. This shows, they argue, that the experience of thinking and the sense of agency in thinking are two separate parts of our idea of owning our thoughts. They go on to suggest that this analysis of thought insertion (that there is loss in the sense of agency) also explains the experience of verbal hallucinations (or at least some verbal hallucinations). That is that hallucinations are (at least sometimes are) thoughts which have not been identified as our thoughts because there is a lack of intention to think (so that thought insertion and auditory hallucinations are similarly based in a sense of alienation from one’s own thinking). This clearly bears some relationship to Frith’s account. It is worth noticing here that this account of these experiences casts hallucinations as a much more disturbing phenomenon than a false-perception account would, because it implies that the person is experiencing a dramatic sense of self-alienation. This is also true of Frith’s and Hoffman’s accounts. There is, clearly, something very puzzling about reports of thought insertion. But this type of phenomenological account of thinking seems to lead to more puzzles. One important issue is whether this account is meant to be an account at a personal level or of a sub-personal process. If it is a sub-personal process then the issues that arise with the Frith type of account are relevant, and in particular whether and to what degree it makes sense to talk of processes in the brain as intentional and purposive. As an account at the personal level it seems removed from our usual experience of our thinking and acting. These attempts to understand these experiences as a changed subjective experience seem to imply that our normal way of identifying our thoughts as ours is based on some private experience. However, there are problems with this idea. This is discussed below in the section on Strawson’s reinterpretation of Kant. Essentially, however, our usual way of identifying whether a thought is mine or yours clearly depends on how we identify people. And we identify people on the basis of physical criteria.

The mereological fallacy One problem with the information processing has been averred to above. It is the homunculus fallacy. A psychological power or state is explained by assuming a version of a little man in the brain or in the mind who carries on the function at one remove. For example, perception might be explained on the basis that light is received in the eyes and transformed into electro-chemical impulses which are transmitted to the visual cortex where they are translated back into an image which Philosophical psychology 73 is perceived by some part of the brain or mind or information-processing system (the problem with this type of explanation being that it obviously doesn’t take us any further). To explain the ability to determine which of my thoughts are my thoughts by invoking a system which compares thoughts to a plan of my intended discourse raises the question of how this system makes this comparison. There is the problem here of an infinite regress. Bennett and Hacker (2003) have argued that the problem is better characterised as the mereological fallacy – that is, the fallacy of applying predicates to a part that is only legitimately applied to the whole. This is actually a different objection to the infinite regress problem. It makes no sense, they suggest, to talk of a part of the body or person doing something that is only properly applied to the whole body or person. So the eye does not see. We use our eyes to see but the seeing is a property of the person rather than the eye. Likewise, they say it makes no sense to talk of a part of the brain making decisions, comparing things, seeing things. This is not an empirical issue but a conceptual confusion. We do not speak of brains deciding things (unless we are using a figure of speech); we know how to apply the concept of seeing to people. We know how the idea of a person seeing might be true or false, but this concept has no literal application to eyes or brains. We specify which thought or feeling we mean by identifying the owner of the thoughts. And we identify the owner of the thought in the case of other people by identifying and differentiating different bodies of the person involved. In the non- pathological case of our own thoughts the question of identifying the bearer of the thought or feeling doesn’t arise. To identify feelings or thoughts isn’t a matter of introspection (when this is thought of as an inner perception). We don’t identify what a feeling is in our own case and then generalise to others, rather we learn to play a game in which we learn how to apply these predicates in a public language, i.e. a language with shared meanings with other people. If this is right then what the psychotic person has done in getting confused about thoughts and feelings may be thought of as being a sign of a disintegration of the system of thinking about myself among other persons, a loss that is of ego boundaries. All this discussion of the identification of states of mind as my own – that is, in distinguishing states of myself from states of other people – does have something about it that is rather academic and divorced from our everyday experience. Philosophers have been impressed by the fact that the way I identify mental states in myself and in other people is so radically different. This has led to sceptical doubts about the existence of other minds, and it has led to the idea that I identify a state of mind as mine by some act of introspection or by some sub-personal process that leads to introspection. This doesn’t really seem to be a plausible account of how one learns that one’s mental states are one’s mental states. The only mental states we experience are our mental states, so there is no need for a special way of telling that this is so. In the normal case we have no need to have a special way of telling our thoughts are ours. They are the only thoughts we can have. The suggestion that we have a sense of our thoughts, for example, as our own thoughts because we have willed these thoughts so that if we have thoughts that we have no sense of having 74 Part one willed we regard them as someone else’s thoughts doesn’t explain why we don’t regard thoughts that enter our mind unbidden as someone else’s thoughts. In particular, why do we not regard our obsessional thoughts as someone else’s thoughts?

Our conceptual scheme and the identification of persons It is instructive to ask how we attribute mental states to others and to ourselves. Peter Strawson takes a Kant-inspired view of this issue in his book “Individuals” (1959). We have the ability to ascribe mental states to ourselves and to others. I can claim that I am in pain, am thinking of going for a walk, feel happy about the future, that I am sitting on or going for a walk. And I can also describe other people as doing all these things. Philosophers have worried about the fact that the grounds on which we ascribe some of these states to others are of a radically different kind to the grounds we use to ascribe these states to ourselves. If we think of our first coming to know the meaning of some of these states from our first-person experience of these states it seems that this is a real problem. Wittgenstein (1953) and Anscombe (1957) have argued that “I” is not a referring term, mainly on the basis that it is difficult to see what it could refer to. Wittgenstein pointed out that there are two types of use of “I”. In one use – the use of “I” as an object – I might say that my arm is bleeding and be wrong about this. There may be a mirror and what I see as my arm is not in fact my arm. The other use of “I”– when I say “I am seeing a boat” it is impossible for me to be wrong about who it is doing the seeing although I may be wrong about its being a boat. He raised the question of what type of ownership this could be, if it is logically impossible for it to have been otherwise. When I say “I am in pain” and I cannot be wrong about who is the subject this seems like an identification of the pain experience rather than a statement of ownership. He points outs that it is difficult to imagine another’s pain on the basis of one’s own pain. I can imagine a pain in your arm. But I will just be imagining me having a pain in your arm (which is conceivable) if when your arm is harmed I experience pain and I locate the pain in your arm by pointing to the injury in your arm. Wittgenstein and Anscombe argued that this showed that “I” was only apparently a referring term and that the function of statements such as “I can see a boat” or “I am in pain” was not to be thought of as referring to a particular subject “I”. One problem with the model, that we learn the meaning of psychological predicates from our own case and then generalise to others, is an epistemological problem. How could I know that other people had mental states like mine when the grounds on which I base statements about other people’s mental states are so different to the grounds I have for making statements about my own case. My grounds for other people being in pain are certain types of behaviour; the grounds I have for my being in pain are of a different type. I don’t learn that I am in pain by watching my behaviour. When someone identifies one of their thoughts as the thought of someone else, or if they identify their actions as caused by someone else, this is not only a misidentification of their own thought; it is a misidentification of someone else’s thoughts. If we experienced pain when someone else’s leg was Philosophical psychology 75 kicked it would still be our pain (because that is the rule for the use of the expression “my pain”). I get the thought “I am a demon possessing you”– this is still my thought. These patterns, however, do depend on the world being a certain way. There is a story by H.G. Wells in which the main protagonist experiences vivid dreams which form a coherent narrative. He wakes from his dream and returns to his waking life, but when he sleeps it is as if he is waking from the dream of his waking life. If this sort of thing started to happen frequently we might find it difficult to decide what the rule should be for the application of the idea of the same person. A further problem, however, is not the epistemological problem, but is the problem of how we can get the idea of other centres of consciousness, or selves, if we try to build this picture up from our own case. It is unclear how we could even get the idea of different centres of consciousness from only our case. Strawson argued that if we try to develop our idea of possession of mental states from our own case we are caught in paradoxes such as these. The dilemma seems to be between a behavioural account of the use of psychological terms and a direct experience. Of course all psychological terms are not the same. Statements about someone’s character are primarily statements about how a person is disposed to behave. If we describe someone as selfish we are really referring to what they are disposed to do, and other people are often in a better position to tell us if we are selfish than we are. Strawson argued that our primary way of individuating and identifying things is in terms of their position in space and time. If we try to individuate a purely psychological being it is difficult to see on what criteria we can determine if it is the same psychological being or a different one. He suggests that the solution to these difficulties is to recognise that we have a concept of a person which is a primitive concept. By primitive he means that it is not analysable into more basic concepts such as “self” or “body” but that we are prepared to ascribe psychological predicates to the same thing that we ascribe physical predicates to. So we can say “I am 5’ 10” tall” and “I can see a red light”. And the primary way we individuate persons is because we are prepared to do this on the basis of physical characteristics. If I wasn’t prepared to identify persons through physical characteristics I wouldn’t be able to identify them at all. If this is correct it has implications for the psychotic experiences of disintegrations that we have been discussing. If we essentially identify different persons (and therefore different subjects of thoughts, sensations and beliefs) by identifying and re-identifying physical bodies, then talk of one person’s thoughts being inserted into someone else’s mind seems incoherent. I am identified through my body. If I say that someone else’s thoughts are in my mind I seem to have lost touch with the grounds by which I identified you and I as separate persons in the first place. And surely this is how in reality we learn to use psychological terms. We don’t just learn first-person uses and then later on generalise these uses to other people. We learn “I am in pain” in the appropriate circumstances, and we learn “He or she is in pain” in appropriate circumstances. This seems to be the real use of the term, and in life we never have to question how we know that our thoughts are our thoughts and other people’s thoughts are their 76 Part one thoughts. There seems something slightly strange about the idea that we (or our sub-personal programmes) determine if our thoughts are our own thoughts, because this seems divorced from the way that we actually determine these things when we learn psychological language-games and when we interact with other people in our daily lives. Identifying our thoughts and feelings and other people’s thoughts and feelings is part of acting towards other people as people. One can distinguish between the macro level and the micro level here. This has some implications for the experience of the psychotic person with passivity experiences. The problems with “theory of mind” may relate not to the identification of our thoughts by some quasi-perceptual process but may operate at the level of seeing and interpreting others as independent, separate people. Strawson suggests that the idea of ownership of mental states at all logically requires a range of subjects of those states. Concentrating on my own case, I may identify thoughts and feelings, sounds and sights, but to identify them as my thoughts and feelings it is necessary that I should be able to distinguish me from you or someone else. And this requires criteria for making that distinction. But if we are trying to work this out from our own case, what could these criteria be? Being able to distinguish owners of mental states from each other requires that we can identify a range of subjects of mental states. And identification of the subject of mental states can only be done through identification through bodily criteria. Furthermore, if this were not the case, why should we not say that there were a thousand “selves” associated with a particular body? He argues that these considera- tions show the primitiveness of the concept of a person in our usual way of thinking and talking about bearers of mental states. But if this is right, what sort of mistake is the psychotic person making who says that he has someone else’s thoughts in his mind? It is hard to see how thinking of other minds could be derived from experience, but is rather a precondition of understanding experience. No experience would convince you that someone else’s thoughts were in your mind, except in the everyday sense in which we say this all the time. We might say that the report of thought insertion is not comprehensible, in that we cannot imagine any circumstances in which it could be true. This is not to say that it is incomprehensible because we could not show it to be true, but rather that it is impossible to fill in the details of the account in a way that we could clearly envisage. Which may point back to Jaspers. 6 PSYCHOANALYSIS

There is an unusual relationship between psychoanalysis and psychosis. For a start, since Melanie Klein described the origin of psychotic states as being in the early months of life at a fixation point where the primary relationship was with the mother’s breast, much of the talk of analysts has been in terms of psychosis, even when they are actually talking about neurotic or personality disordered clients. Actually, according to the Kleinians we all become psychotic in the transference. A supervisor I had at the Tavistock clinic said that most people spend most of their time in the paranoid-schizoid position, and that if you were riding a motorbike in London this was a very useful thing. Much has changed in psychoanalysis since the 1950s, but the language still remains. The other slightly odd thing about the relationship of psychoanalysis to psychosis is that very few analysts see any psychotic patients at all. However, this rather ironic situation isn’t completely hopeless. Some analysts do see psychotic or even “schizophrenic” patients and the models of psychotic processes are thoroughly psychological, which is a great relief if you are a psychologist and earn your living by promoting psychological ways of thinking about these matters. In fact the description of ordinary persons in terms of psychotic mechanisms (which the analysts surpass at) will lead us to another type of normalisation. Normalisation through abnormality, if you like. Not so much that the mad are really sane but mistaken, but more that the sane are really just as mad as the insane. Psychosis becomes understandable because psychotic processes occur in sane persons. In this chapter I will briefly explain the classic model of psychosis according to psychoanalysis (although of course in reality there are a variety of views as in any discipline, but there isn’t space to follow every variation). I will go into a bit more detail on Norman Cameron’s model, which puts these ideas to use in an explanation of the development of a paranoid psychosis. Finally, I will discuss in some detail the psychoanalytic accounts of schizophrenia in R.D. Laing’s “The Divided Self” and of Christopher Bollas, who has worked extensively with people with a diagnosis 78 Part one of “schizophrenia”. He describes a model of “schizophrenia” and goes on to talk about modification in technique in a way which is very interesting for anyone interested in working psychologically with people with psychosis.

Introduction to psychodynamic concepts Psychoanalytic ideas are often couched in terms of early experiences of the infant or child, in the case of Melanie Klein, in terms of the fantasies of the infant. And yet the data for these hypotheses are drawn from psychoanalytic sessions of adults (or sometimes from the play therapy of children). Obviously, there is no direct evidence about the experiences of infants from sessions with adults, so it is sometimes unclear the degree to which these hypotheses are meant literally or are used as metaphors. Be that as it may, Klein describes the infant as relating to others from the very beginning of life, either to people (the mother) or to part-objects (a part of the mother). Psychoanalytic thinking has developed without much communication with ideas from outside, so I will review some of the basic concepts before discussing how they relate to clinical psychosis. An important fact about psychoanalysis is a change that took place after Freud wrote “Remembering, Repeating and Working Through” (1914). Psychoanalysis had begun as an attempt to trace the symptom to its historical origins (a trauma) which had been repressed. Once the memory was recovered (the repression overcome) and abreacted the symptom would disappear. (A little like schema therapy today.) At first Freud and Breuer had used hypnosis to achieve this end (hence the analytic couch) but later (partly apparently because Freud wasn’t very good at hypnotic induction) the method switched to free association, so that simply by saying whatever was on the patient’s mind the traumatic origins of the symptom would be revealed. In “Remembering, Repeating and Working Through” Freud suggested that clients enacted their problems in the relationship with the therapist, particularly at the beginning of treatment. What was important was to analyse the development of the relationship of the patient to the therapist, rather than to focus on recovering a memory. This had the advantage of meaning that the problem could be seen by the therapist in the room. People talk about the past in the present. This can be confusing because sometimes an analyst will talk about a psychological process in terms of it being from the child’s past but the evidence will be a process occurring in the here and now of the psychological session. This may not be so problematic if, for example, we want to generalise from the client behaving in, say, a deferential way towards the therapist to an early experience of the client behaving in this way to his father or to a father figure, especially if the patient confirms this by acknowledging the link. However, once we are discussing the fantasies of a three-month-old infant in relation to the breast, for example, it seems we are on far more difficult ground. The assumption in analytic theory that if something occurs in the transference it must be a pattern from childhood is really an assumption made by the model. The behaviour of the client in the therapy session is no evidence for it. Psychoanalysis 79

One of the aspects of psychodynamic thinking that seems distinctive is the attribution of meaning to psychological symptoms, and further that this meaning is unconscious. Freud makes it clear that he doesn’t think it inevitable that the issue that arises in the transference is a duplication of the exact problem the person faced with his or her parents. Clearly, apart from this, psychoanalysis is a radically different model. As well as the concept of the unconscious as the primary motivator of behaviour, other central concepts are the defences of projection, projective identification and regression; regression to an earlier time in the person’s development and regression to a more primitive type of thinking, feeling and relating. Anthony Ryle (Ryle and colleagues, 1997) (a British psychiatrist who was a nephew of Gilbert Ryle, the linguistic philosopher and the author of “Concept of Mind”, a seminal work in the philosophy of mind) has suggested that these processes can be thought of more coherently in terms of role theory. There are a series of reciprocal – that is, complementary – roles, which people can fall into. These roles when they are dysfunctional tend to be black or white and not flexible. Examples might be brute and martyr, bully and victim or cared for and carer. These types of split are always reversible, so that someone who feels victimised has the potential to be a bully. What is taken in is always a relationship type rather than one pole of this relationship. Ryle queries whether these processes are defensive. He suggests that the primitiveness of the thinking (black or white thinking) can be explained as an immaturity in thinking rather than a defence. Klein (1975) thought of these defences as regression to an early stage of life and as the fixation points for “schizophrenia” and bi-polar disorder. She called this the paranoid-schizoid position. But this was largely based on the idea that the origins of psychiatric problems lay in the infantile past, so the most serious problems must lie in the distant past. So the idea of splitting may be taken from the phenomena in “schizophrenia” and bi-polar disorder in the first place. Freud got the idea of the superego – a separate part of the self which judges, observes and criticizes – from the experience of clients with “schizophrenia” having the experience of being observed and hearing voices commenting on and judging their behaviour. What, he asks, if the psychotic patient were right and they were the subject of constant observation, criticism, and even persecution. He also says that this phenomenon is known to us in everyday life as the agency of conscience. So it may be no great surprise if these analytic ways of thinking seem to explain psychosis in psychological terms. This is where they came from. One way which this can happen is through projection and introjection. Klein described this process as projecting hostile impulses towards the self and then introjecting the perceived hostile object; actually, “part-object”, as the infant is taken to be relating to parts of the mother rather than the whole person. This is related to the main defence mechanism that the infant is taken to be using – splitting. Being aware, or so the story goes, of times of deprivation and times of satisfaction (i.e. being fed or being hungry), the infant imagines that there is a good and a bad object it is relating to. This is to keep the good safe from the bad. This makes infants sound rather like 30 year olds in analysis. Norman Cameron (1943, 1959) applied these 80 Part one ideas to describe this process in some detail. Precipitated by some conflict, the person begins to be frightened of their hostile feelings, which are projected out into other people. Perceiving others as hostile, the person becomes more anxious, more hostile and projects these feelings into others. One influential idea in psychoanalytic thought is that the self is divided into separate parts. Pretty obviously this idea precedes psychoanalysis. But it has been an important idea in understanding people from a psychodynamic perspective – that people are divided into sub-personalities. Freud’s hypothesis of the “superego”, the id and the ego implies that the self is divided, and furthermore that some parts of this divided self is not accessible to awareness. The detail of how this works out in Freud’s theory changes as his model changes, but the basic idea stays the same. Actually, he says that he got the idea of the superego from patients who had delusions of being observed and auditory hallucinations commenting on what they were doing. He asks, what if these patients are right and they are being observed (and implicitly judged), not by an external force but by a part of themselves, representing society’s standards? That is an internalised parental figure. He mentions that one criticism of this might be that it seems to reify a common idea (viz. conscience). Clearly the idea that man struggles and is in internal conflict is to be found throughout history. Sometimes this conflict was, however, thought of as a struggle between external and internal forces (that is, spirits or demons). In “Mourning and Melancholia” Freud describes how a patient can mould themselves on the basis of someone that they have an important emotional bond with. They can take on the characteristics of the person that they relate to. Or in this case actually the characteristics of the person that they have loved but lost. Depression is introjecting the loved, lost person and then directing hostility towards them (but towards oneself identified with them). The idea of identification is the idea of basing oneself on someone else, and this can be the basis of separate, different selves in the same person.

The concept of the unconscious and its relation to psychosis The psychoanalytic model of the mind includes several important hypotheses or ways of thinking about the mind in general which affect the model of psychosis. First of all there is the hypothesis of the unconscious. This “unconscious” isn’t really anything like the “cognitive unconscious”. At first Freud thought of the unconscious as a repository of motives and drives. These motives and drives (usually about sex or aggression) were actively avoided – repressed – and it was this repression that rendered these drives and motives unavailable to the conscious mind. As well as motives and drives, particular memories could become repressed. He came at the hypothesis through investigation of “hysteria” and was, at first, involved in uncover- ing unconscious traumatic memories (often of sexual abuse). However, he later repudiated that theory and began to attribute many of the recovered memories to unconscious wishes and to see the memories as defences against these motives. Later the theory changes and Freud thought that as well as “basic” motives such as Psychoanalysis 81 sex and aggression, motives such as guilt could also become unconscious (so that part of the “superego” could become unconscious. This is a considerable change in the model. Another important part of the model is that the unconscious is thought of as the most important or influential part of the personality. I will return to the more general model later to discuss the importance of the work of Melanie Klein to psychodynamic ways of understanding psychosis. However, for the present there are two features of Freud’s thinking that are important to his understanding of psychosis. First of all it is important to understand that psychoanalysis conceives of the unconscious as involving a different, more primitive type of thinking. Freud labelled the “primary process” in contradistinction to the “secondary process”. His thinking about the unconscious was formed from his attempt to understand dreams. Dreams have a meaning, but it is a hidden meaning (due to repression) and it is told in a language which is not the language of the conscious mind. This is because the unconscious involves this more primitive way of thinking. He describes a number of important ways in which dream thinking (and the unconscious) differs from conscious thought. First thinking is in images. He mentions an experiment in which the experimenter observed that as he fell asleep his train of thought turned into a related series of images, and became more focussed on expressing the process of what he was thinking about rather that the content. Freud thought that this demonstrated the process of thinking changing into the imagery of dream thinking (or thinking in the unconscious). Consistent with thinking being in images, he also thought that thinking was through means of symbols. Some of these symbols were derived from the person’s own experience, but some symbols went beyond personal experience. For example, a client of mine had a dream after a traumatic sexual experience in which he dreamt of snakes with beaks. These seemed quite straightforwardly phallic in meaning as an expression of his ideas around these; however, he later saw a documentary about ancient South American art and he saw the same images that he had seen in his dream. He wasn’t interested in art so it seems unlikely that he had previously seen these images. In any case, this is the sort of example that Freud had in mind in referring to symbols which went beyond the person’s own experiences. Jung talked of the collective unconscious, as a repository of such images, as the source of ideas in religion and magic. The images in the unconscious can be subject to a number of processes. One of these is condensation. An image may represent several ideas at once. The usual process to elucidate this is to ask the person to associate to the dream. What comes to mind when they think of the dream? This is supposed to bring out the meaning of the dream for the particular person. This is another feature of the unconscious. Links are made by association. There is also no idea of time in the unconscious and no idea of contradiction. Contradictory ideas or impulses can be held simultaneously. A client of mine told me that he had two dreams. In the first dream cows were invading his garden. He felt scared and locked the doors against the cows coming into the house. In the second dream he was watching a woman being gang raped by a group of men. The main problem in his life at that time was the end of a long marriage. He felt responsible for the end of the marriage and had recently moved 82 Part one out to live on his own. These images, or stories, seem to express his fear of his new situation, the vulnerability of being on his own, but also possibly his fear of punishment for his marriage having failed.

Projective identification Projection or projective identification is the psychological process in which an unacceptable feeling is located in someone else. So if I find my feelings of hatred unacceptable I can project these feelings into someone else so that I see them as aggressive and hateful. This was used as part of an explanation of racial hatred. I attribute to other racial groups unacceptable feelings or motives. Those other groups of people are avaricious or lustful or purely self-interested. Actually, the concept of projection isn’t quite this. Although I can imagine that others are hateful, for example, when they aren’t, the idea of projection in analysis, at least these days, involves having a real effect on the person projected into. As well as particular emotions/motivations (hatred, lust, envy) parts of the self can be split off and projected out. This can include sub-personalities as discussed below but can also include parts of consciousness. So, for example, Bion (1957) talks of projecting the faculty of observation. So a psychotic patient can sense that they are the object of observation because they have projected this faculty into someone else or into an object, e.g. the light bulb or the television . . .

Inner objects Relationships that we have with other people are “internalised”. We learn to relate to others and to ourselves on the basis of these relationships and analysts describe this as the internalisation of objects; hence, inner objects. Originally Freud described this in melancholia. He suggested that after a loss a depressed person attempted to preserve the relationship with the lost person by internalising that person, and the self-directed criticism is based on qualities of the lost person. This has been developed as a major part of the model. Characteristics of other people, and of our relationships with others, change the person’s personality, or rather originally are the basis of the person’s personality. These inner objects can then be projected out into others, so that there is a process where characteristics of others become the basis of our personality. These can then, in turn, inﬂuence other people’s reactions to us. Deborah Steiner (1989) has talked of the internal family, on these lines.

Splitting and projection Splitting is the process whereby either oneself or the person that one is relating to is split into two parts. The theory is that this is done as a defensive manoeuvre so that one can keep the good separate from the bad. At different times the person who one is in a relationship with (the object) is seen as all good or all bad, so that the Psychoanalysis 83 good and bad are kept apart. A borderline patient who uses this type of splitting may feel that their partner is completely good at one time and completely bad at another time. This process is a form of dissociation where the ideas and feelings of the person at one time are isolated from the ideas and feelings of the person at another time. Furthermore, not only can the object be split in this way but the self split into separate good and bad parts. A common example of this process is the person who divides people up into those who are good and those who are bad. At one point an explanation of racial prejudice was that people were divided into the good and the bad depending on race so that the bad qualities of people (oneself or someone else) could be attributed to another racial group. Hitler’s idea that Jewish people were unable to cooperate with others and sought to undermine the white race because of envy has this sort of feel to it. These processes are taken to be universal to differing degrees. Projection is the associated defensive process. Unacceptable feelings or motives are split off and projected into other people. Actually, the example of race hatred just given is an example of splitting and projection. Selfish motives are split off from the rest of the self and projected into people of a different racial group – or into institutions. This basic idea – that unacceptable feelings or motives are disavowed and located in other people – is used in a number of ways. As well as bad parts of the self being projected out, good parts of the self can be projected out to be kept safe. So I can think of myself as a worm and locate all the positive qualities in my partner, or in a pop star, or in a demagogue or a religious figure. An important point here is that these processes are not simply in imagination. Projective identification has a real effect on the person related to. The other person begins to act out the part projected out. So in a couple, one person can find their feelings of hostility unacceptable and project these feelings into their partner. The partner then begins to act on these feelings and becomes hostile, so that there is an imbalance. In a healthy relationship both partners can have positive and negative feelings about the other and this leads to resolution of problems and a reduction in the strength of the negative feelings in the relationship. One important issue is the evidence on which these claims are made. Clearly we can make empirical hypotheses about things that we have no direct evidence of. Sometimes we infer from distal evidence processes that we cannot directly observe. However, the evidence for analytic hypotheses is derived from the psychotherapy of adults. The processes described of splitting and projection are mainly observed in the relationship between the therapist and the patients, i.e. in the transference. It is an act of faith on the part of psychoanalysts that these phenomena are re-enactments of early childhood experiences. This part of the theory is not tested and the use that these statements are put to is in interpretations made to clients in therapy. So an alternative possibility is that these hypotheses are actually metaphors of some emotional connotation. To say that someone is relating to me as a depriving breast or an all-bountiful breast is to use a metaphor with powerful associations, rather than being a factual hypothesis. Mainly psychotherapists are concerned with having a therapeutic impact on the patient. 84 Part one

The paranoid pseudo-community Norman Cameron (1959) pulled together some Kleinian ideas as an explanation of paranoia. Cameron is interesting, as he was an academic psychologist who later trained as an analyst. He wrote a paper explaining paranoia in social-psychological terms and then once he had trained as an analyst he rewrote it using Kleinian ideas. People who are prone to psychotic paranoia, he argues, have a tendency to have difficulty in relating to others, inherited from childhood. In crisis, this type of person regresses to more primitive defence mechanisms (i.e. splitting and projection). This is accompanied by a social withdrawal. The person becomes more preoccupied by their thoughts and feelings and relates less to others. Unfortunately, this social withdrawal removes the reality check of others. Their emotional reactions and thinking become more based on these primitive mechanisms. Feelings of self- destructiveness threaten the person’s safety and are projected into others. Projecting feelings of hostility into the environment makes them feel threatened by other people rather than from inside. This produces anxiety, which produces further projecting out of feelings of hostility. Cameron then suggests that being anxious tends to heighten perception of potential sources of threat and the person begins to see threats in a variety of different places, which again heightens the person’s sense of anxiety; the sense that they are in danger. He suggests that anxiety heightens perception of danger and the perception of neutral stimuli as threatening or dangerous. Ultimately, the person forms a delusional belief as a way of understanding why they are being threatened and where the threat is coming from. The person begins to explain the threat as due to the agency of particular people who have a particular goal in mind. It might be that the person concludes that they are under surveillance from a foreign spy agency. Understanding where the threat is coming from increases the sense of predictability of the threat, and this is anxiety reducing. Moreover, the person is trying to re-establish contact with people through the formation of a delusional world. The secret agents who are spying on the client are the people whom the client is trying to bond with. At least they are not alone. Here parts of Cameron’s account has similarities to a CBT account of delusion formation and maintenance. Once a paranoid delusion is established (what Cameron refers to as the paranoid pseudo-community), the delusion is reinforced by being anxiety reducing. This, then, is a social psychology reinforced view of the dynamics of paranoia. It is not an attempt to explain psychosis as a whole. Voices enter into the explanation as part of projected out parts of the self. Once the paranoid belief is established it reduces anxiety, because the person now knows where the threat is coming from. The person’s paranoid belief system will also influence those who he or she thinks are persecuting him or her. Also, although the supposed people in the paranoid system are malign, it is still a form of human contact, so this is an advance from the regressed state that the delusion emerges from. One interesting aspect of this explanation is that the formation of a delusion is a positive achievement, and a move towards health. The explanation of the beginning of the paranoid state, and the engine driving the psychosis, is the idea of withdrawal from social reality and the concurrent regression to primitive modes of thinking and relating viz. splitting and Psychoanalysis 85 projection. Once the delusional system is formed, the characters in the delusional system – the “paranoid pseudo-community” as Cameron calls it – will all be, in part, figments of the person’s imagination. The person will be relating to people on the basis of projected-out parts of him- or herself. A client of mine believed that when she went out into the street she was under observation by spies who kept her under surveillance with the intent of either using her for their own ends or making sure that they knew what she was doing. She was relating to these people not as they really were but as how she feared they might be. So in this sense this was a narcissistic form of relationship. She was relating to herself; living in a world of her own. Although she did not make this connection herself she felt that she had done things in her life which she felt guilty about. She felt that her mixed marriage was beneath her. There were also things which she had been blamed for by others. She had also been unfaithful, for which her husband had never forgiven her, and she had abandoned her children. The feeling that she was observed by hostile forces can be thought of as her own feelings of guilt which had been projected into these strangers, who represented a part of herself. Whether this is the correct understanding of this particular example is, of course, a matter of debate. Bion (1957) in his writings about “schizophrenia” hypothesises that not just emotions and motives but other parts of the self can be split off and projected. This can include a function of part of the self (such as the conscience) but also the power of sight, so that feeling observed comes from having located the power of seeing in some person or object. This can explain delusions of reference, or of being spied on. Obviously in these cases the person must also know that they can see or hear in the usual way. This must be reference to the breakthrough of unconscious thinking into the conscious mind. Neville Symington (2002) in his book “A Pattern of Madness” attempts to explain his theory of narcissism in language which eschews the technical language of psychoanalysis and uses ordinary language and the language of religion. He gives an account of narcissism which he holds to underlie most psychiatric presentations and, indeed, most human problems. This theory then attempts to explain “schizophrenia” and psychosis as the outcome of pathological processes but pathological processes which are exceedingly common. It is normal to be abnormal. Furthermore, it is an attempt to explain “schizophrenia” as an extension of problems in relating to others. The symptoms of “schizophrenia” are meaningful and unconsciously motivated, i.e. actions rather than things that just happen to a person. He has reframed the ideas using common language and religious language. Thus instead of talking about an internal omnipotent, persecutory object he will talk of having “a Devil” in you. He describes the personality in terms of an inner jelly and an outer crust, bits of which are made more jelly-like or more crust-like by the operation of what he calls “intensifiers”. These intensifiers are the negative emotions/motivations of greed and envy which when unacknowledged have a detrimental effect on the personality. The jelly and the crust are opposed to free action which originates in the self, and while a person is trapped in jelly or crust they are unable to engage in free action. Other aspects of this model of the personality 86 Part one are paranoia, God and the worm. People can be identified with God in which case they relate to others as the worm, or they can be identified with the worm and see God in others. This way of thinking about the mind has the advantage of being more emotionally meaningful to clients than the usual technical jargon of the analyst. Here the talk of the parts of the mind is metaphorical, but it can be difficult to be clear about where metaphor starts and ends. Talk of an unconscious mind or even a conscious mind has been thought of as a metaphor by some. Symington would see people adopting the roles of being God or the worm as things needing to be understood and then moved beyond. However, in therapy he says that often the therapist is identified with God, and this leads to a problem. If God makes interpretations then the client may take these on as commandments without really owning these ideas themselves. He suggests that often it is best to be aware that one is being seen in this way but to allow interpretations to come from other people in the person’s life, rather than risk being given the interpretation with the force of an act of God. He suggests that using this rather novel way of thinking about the mind and in particular the narcissistic mind – as his model is really one of narcissistic personality – it is possible to understand “schizophrenia” in these terms. Symington was influenced by Bion’s theory of alpha functioning. He thought that one can distinguish between unprocessed quasi-sensory mental content and creative mental thought. The latter (alpha function) was not defined by Bion, but an example is the mother’s thinking about the child’s emotional state, where the anger and frustration of the child can be transformed by her reaction. Symington talks about this as a creative thinking process, and he largely identifies this with psychological health. He suggests that “schizophrenia” can be described in terms of his theory of narcissism. He suggests that thought disorder (what he calls flight of ideas) can be understood as a lack of thinking or “alpha function”. It is not a matter of something being wrong with “associations” but that thinking is a personal and creative process, which is totally different from a mechanical, associative response. Thought disorder is a lack of a creative act; the central governing process is missing. Fixing on passing sensory impressions (in thought disorder) is a manifestation of “glue-like attachment”, attachment to an embodied God. Symington is contrasting psychological health in which there is creative thinking and emotional contact with another. Thought disorder on this account is a flight from inner mental creativity. Symington analyses ideas of reference as having God installed in the person. Because God is installed in the person so that everything relates to him or her. Hallucinatory voices are analysed as God being installed outside the person and speaking to the person. This is why voices are perceived as all powerful and judgemental. Concrete thinking is again an example of unprocessed quasi-sensory perceptions. He contrasts having a genuine intimate relationship with responding in an automatic manner, based on the dictates of God. One motive for this retreat from thinking is to escape freedom (the freedom of taking responsibility for one’s actions and authentically acting on the world). One great advantage in this way of thinking in therapy is that it is human language and less objectifying, which may help rather than hinder understanding. Psychoanalysis 87

Carl Jung’s theory of “schizophrenia” Jung (1935) thought of the unconscious mind as having an indeterminate number of “complexes” – that is, complexes of associations. He was influenced by the idea of the mind as a series of associations, and Freud’s use of free association to discover underlying traumatic memories and present unconscious difficulties influenced this. These complexes of ideas were not integrated with other ideas, and this is what made these sets of associations “complexes”, i.e. a number of interrelated ideas. Jung used word association tests to divine underlying significant sets of ideas. Unusual associations or prolonged reaction times to particular stimuli were used by him to make inferences about the patients’ problems. However, Jung also thought that these sets of associated ideas could have intentions and motivations of their own. It was a sub-personality which was dissociated from the main personality. Jung developed this idea. The perception of oneself as a single unified self or ego, he said, was merely an illusion. The unconscious is composed of a series of “complexes”; these are a group of associations which cohere around a troublesome idea or experience. It might be around a trauma. Many of these complexes are not known; they are unconscious, but are known through their effect on behaviour or on relationships – for example, with the analyst in the transference. Jung, however, says that these complexes have a body and intentions of their own. If I intend to give a speech but I become anxious and my voice trembles or I stammer, I am under the influence of a complex. However, it is not clear how a complex of associations can have intent opposite to that of the person who has those associations. How can a memory or an associative link between, for example, previous humiliating experiences, have an intention? It seems this is the wrong sort of thing to have intentions or motivations. He was interested in ideas as based on associations, and has used word association as a test of unresolved conflict, but his theory seems to be left behind here. He is describing sub-personalities. Some of these are based on relationships with others (parents, partners, brothers, sisters), but some he thought were in the “collective unconscious” – that is, not derived from personal history but archetypes derived from man’s common history. These sub-personalities could be experienced in dreams. He also thought that the origins of voices or visual hallucinations in “schizophrenia” were experiences of these sub-personalities. So the voices of a paranoid patient were a part of the patient talking to him. The same would be true of delusions; the persecutors in a person delusion are a part of the person plotting against him, to harm him. As these sub-personalities exist in the unconscious, it is also true that in psychosis the person gets closer to, or experiences, the thinking of the unconscious. Thus psychotic experiences are a kind of truth.

Psychosis: application of psychodynamic ideas to thinking about psychosis Arieti’s (1974) approach to working psychodynamically with “schizophrenia” is of some interest. Some analysts (e.g. Hanna Segal) have maintained that the approach 88 Part one used in psychosis could be the same as that used with non-psychotic disorders. Arieti was not of this school. He understands “schizophrenia” to involve a change in thinking. Psychotics are stuck in a dream state. They are flooded with the contents of the unconscious. What they experience can be interpreted to have meaning but they are not aware of the symbolic nature of what they experience or believe. Arieti thinks that because of this a different approach is needed. His work is of great interest, as he has several suggestions to make about helpful and unhelpful technique with “schizophrenia”. Given the extremely isolating effect it can have, Arieti suggests that the first important step in psychotherapy is to establish a friendly working relationship with the client. Once this is done he suggests a number of techniques which can be helpful to deal with specific psychotic symptoms. One of these is talking to the client about the “listening attitude”. He suggests that when a client hears voices they are previously in an expectant state. They are expecting to hear voices so they, albeit without realising it, listen for them. Arieti used to take this up with the client, at the appropriate time. Going through examples where the client has heard a voice, Arieti explores with the person whether that had an expectation of hearing a voice prior to it occurring. He suggests that although some clients are resistant to this procedure, if it is pursued they will be able to identify this prior state. And this is not odd, because the voices come from the person’s mind, after all. This approach of looking out for the prior mental act would lead to an improved understanding of the nature of the voices (i.e. that they are products of his mind). A similar approach was also suggested for dealing with delusions of reference, noticing the special meanings of puns. He would talk to the client about how they were subject to a special way of thinking (concretisation) and that this led them to make certain associative links, so in the person with delusions of reference he would investigate the person’s mood and state of expectancy prior to the experience. He would persist with this and found that some clients who at first could not accept this would later become convinced of it. He described the difference to traditional psychodynamic interpretation in the following way: whereas in traditional psychodynamic therapy interpretations were made to show the patient the unconscious meaning of their thoughts and actions (i.e. clarifying the person’s own motivations), in psychosis the aim of interpretation was to clarify the relationship between the client’s thoughts and the world. Harry Stack Sullivan also reported altering the technique for people with “schizophrenia”. He would begin by admitting the client to a hospital where the negative expectations about relationships with other people could be disconfirmed, prior to beginning to talk to the person about his or her life. He also used alcohol to reduce a person’s anxiety about relating to others in the hospital setting. It could be seen as a type of exposure therapy.

The divided self: schizoid states, “schizophrenia” and the self In his book “The Divided Self” R.D. Laing (1965) offered an analysis of “schizophrenia” in terms of existential phenomenology as a variant of the traditional Psychoanalysis 89 psychoanalytic view of psychosis. He had trained at the Tavistock and had worked with Winnicott and was also inﬂuenced by seminars that he attended in existentialism. It is a particularly interesting account, as he tries to describe not only the changes in the person’s phenomenology but also the implications and consequences that this change has in the person’s life; the change is in the way in which the person relates to himself and others, and how this can exacerbate the problem. He is interested in the changed phenomenology of people with “schizophrenia” (at least in this book he was). He is interested in the change in the person’s experience of the world – both the experience of themselves as a person and their experience of others, which interrelate. Laing describes how a sane but schizoid state of mind can progress to a schizophrenic state of mind. He begins by describing the schizoid state of mind in terms of existential phenomenology (but also at root a psychodynamic account; as an analyst his basic model was psychoanalytical and he is proposing a variety to that account).

Ontological insecurity He contrasts two ways of relating to the world. “Ontological security” and “ontological insecurity”. An ontologically secure person has developed to take for granted certain things about themselves and the world. These are largely the very basic assumptions of our understanding of our conceptual scheme of the world (see Strawson, op. cit.). They take for granted that they exist, that they persist through time as the same person and that they live in a world populated by other people, who similarly exist and persist. They see themselves as the source of their actions and they are involved in relationships with other people of whom they assume the same. The ontologically secure person identiﬁes with his body, which locates him in time and space. He goes on to describe the ontologically insecure person in contrast to this. To be a body is to be tangible, to be in the world along with others, to be capable of being touched. The ontologically insecure person, he suggests, has no such certainty about their existence. They do not take for granted that they exist, or that they are the same person today as they were yesterday. They do not take their existence for granted but spend much of their time trying to prove to themselves that they exist or to protect themselves from destruction. These different orientations to the world lead to different preoccupations, motives and goals. For the ontologically secure person the goals are to achieve things, make relationships to interact with the world to increase satisfaction, etc. However, for the ontologically insecure person the goals are to do with trying to prove to oneself that one is alive or to get others to do this. He says that some people are born with a sense of themselves as existing in the world and with the world. Being-in-the-world to use the Heideggerian expression. However, he was an analyst and his account draws heavily on psychodynamic ideas of psychosis and the mind. Also being an analyst conditioned the way in which he thought about clients, I think. Laing suggests that underlying many emotional disorders (and he is not thinking of psychosis here) is a 90 Part one schizoid way of relating to the world and to himself. In this hypothesis Laing is partly following the Kleinian tradition. He goes in to try to elucidate schizophrenic states using ideas developed in thinking about schizoid states. He makes a number of claims. People who develop a schizoid way of relating have a lack of certainty in their own existence. Schizoid people experience a split between their mind and body. This goes with the former proposition, as it is their existence as a continuing, integrated person or mind that the schizoid person doubts. He contrasts this with a healthy experience in which we perceive ourselves to be embodied, and uniﬁed with our bodies. We experience ourselves as persisting in time. He has a number of conjectures about how this might have been caused, but these are not central, and the essential point is that the person is unsure of their own existence; they do not experience themselves as solid and relating to a solid world. As an example, he takes the case of an agoraphobic woman whose anxiety about leaving the house he inter- prets as due to the fear of annihilation when being seen but not acknowledged in the street. One strategy for convincing oneself that one exists is to see recognition of oneself in the eyes of others, and the schizoid person may spend much time trying to achieve recognition by others, not through self-aggrandisement but in a desperate effort to persuade himself that he exists. Such a person spends their time trying to convince themselves that they exist. He suggests that this analysis in terms of existential doubt rather than unconscious impulses explains much of the problems that the person presents with directly without recourse to unconscious impulses. However, it is related to the Kleinian conception of the self, as discussed above. He is also developing the ideas of Winnicott. He suggests that one way of dealing with this state of insecurity and doubt is to develop a false self. So there is a split between the person’s mind and body and then another split between the person’s true self and false self. The schizoid person can develop a false self which interacts with the world, while the true self remains hidden. Such a device means that the person may seem to have no observable problems to others, may hold down a job or a marriage but at the same time feel that this is all an act. This condition of living means that the person becomes increasingly isolated from the real world. Normally, people are strengthened by their interactions with others, but the person in this state of mind becomes increasingly isolated. In this they can be described as narcissistic (in that they increasingly relate to their own ideas and relate less and less to others). They are trying to relate to themselves as a replacement for relating to others, but this is, in the end, impossible. Becoming increasingly isolated, the person becomes more and more fearful of others and less and less involved with what they are seemingly involved in in their life. Laing gives the example of a man who said that he had never had sexual intercourse with his wife, although he had slept with her regularly, because he felt that he was not really present. As well as alienation from the body the person can also experience alienation from their own feelings and desires and futures. This schizoid state is accompanied by a changed perception of the self. By this I mean that the person’s relationship to his own motives, thoughts, feelings and desires are changed. To keep safe from the petrifying gaze of the other the person Psychoanalysis 91 can depersonalise themselves, or they can depersonalise the other. This gets rid of the feared interrelationship. The schizoid state is a sane state of mind but can progress to a psychotic state of mind, but this is only one possibility. He is at pains to point out that other outcomes are possible. He suggests that in itself there is nothing inherently pathological about the ontologically insecure position. Another possible outcome is artistic creation, or some types of religious practice.

Fears contingent on ontological insecurity The ontologically insecure person is beset by three fears in relation to other people. The first anxiety is of engulfment by the other person; the second is implosion; and the third is petrification. These all relate to the sense that the person has of being unsure of the solidity of their existence. These are all sane experiences, but Laing suggests that they can lead to psychotic experiences and that these psychotic experiences can be understood as extensions of these schizoid, ontologically insecure experiences. One pathway to psychosis can be through this sort of schizoid state. There is a changed phenomenology. But this is a clearly psychoanalytic account. Much of what happens with psychotic people is a consequence of the person’s attempts to deal with their fundamental fear or insecurity about existing. Withdrawal from others is a way of coping. Social withdrawal is in service of protecting the self from attack. In psychosis the process of splitting becomes more profound. It is a retreat from relating to others in fear of being destroyed by them. Laing gives an account of how the process of becoming psychotic can be seen as an understandable progression from a sane but schizoid state of mind. He gives an existential-phenomenological account of this process, but, as an analyst, his account is also firmly embedded in the psychoanalytic tradition. Really it is a variant of the psychodynamic account of psychosis. He begins by describing the schizoid state. Two central features of the schizoid personality are the lack of certainty in the existence of oneself and the sense that one is not identified with one’s body; a sense of disembodiment. For Laing, the primary feature is the lack of assurance that one exists. This leads to a lack of a sense if embodiment (i.e. that one is identified with one’s body). This insecurity of one’s existence is defended against by not identifying with one’s body. This could be described as a Cartesian disease, as it is reminiscent of Descartes’ view that a person’s body is contingently related to them and that we are not to be identified with our body. Three fears affect the schizoid person. Fear of engulfment, fear of implosion and fear of petrification. The ontologically insecure person is afraid that contact with someone else will threaten their insecure existence, they will be taken over by the other person, and they may begin to take on the characteristics of the other so that they feel that their personality has been taken over by the other person. This leads the schizoid person to avoid contact with others or, in any event, to be conflicted about emotional contact with other people. 92 Part one

Implosion is a related phenomenon; the experience here is that the external world will in some way overcome the person’s sense of self. Petrification relates to the role that being the object of another person’s perception can have in either confirming or denying the subject’s existence. For the person who does not have a firm sense of themselves as existing as a flesh and blood, a solid person being perceived by others can either confirm or deny their existence and therefore has a totally different importance to that which it has in someone who never doubts that they exist. All of this very much draws on existential ideas and themes. His explanation of the progression to psychosis, however, is more classically psychodynamic.

Development of psychosis The schizoid person has a basic split between their mind and body. This split is motivated by wanting to keep the self safe from threats and dangers of the world. However, this splitting has the effect of isolating the self from any direct relationship with other people. The schizoid person relates to the world through a false self and a gulf develops between the person’s true self and the false self which carries out the interactions with others. However, this lack of direct contact with other people has deleterious effects on both the self and the perception of the world. A sense of aliveness and reality depends on interaction with other people, so that by isolating oneself from others there is a decrease in the sense of oneself as alive and real and of others as alive and real. The person is living a pretence of a life and the true self sits back and observes this process. There is a growing split between the person’s real self and other people; they become more and more distant from the world – that is, from other people. Also the feeling of being alive depends upon the experience of relating to others, so that in confining him- or herself to a self-imposed prison the person feels less and less real and alive. Increasingly, the self is reduced to the functions of observation (observing the false self system) and fantasy. This regression into fantasy (and relating to the person’s internalised objects) has other effects. The rules of fantasy are magical and anything is possible, so the person begins to lose touch with the rules of consensual reality. The internalised objects tend to increasingly become idealised or persecutory. It is the retreat from the rules that govern our experience of the world, where what we are is bounded by the limits of reality. For the incipi- ently psychotic person they are set free. One of my clients (discussed above) had been in an unsatisfactory relationship with a woman for some time. He couldn’t decide whether he wanted to be with her and would find that he changed his mind about this throughout the day. He would go to visit her, decide he did not want to be with her and go home. This conflict was part of the precipitants that triggered a psychotic break. When psychotic, he began to believe that he was the King of Australia. On this model, this belief is understood as a retreat into fantasy; the difficulties involved in his flesh and blood real relationship which caused him such pain were avoided and he retreated to identification with an idealised fantasy figure, the King of Australia. The explanation of the delusional belief being that he had regressed into a more primitive state of consciousness, cut off from the outer world. Psychoanalysis 93

Another effect of isolation from relationships with other people is a weakening of the sense of identity that the person was trying to protect. This leads to further splitting of the self. Some hallucinations are to be explained as the result of this type of splitting. The person’s sense of self splits so that one part of the self is dissociated from another part of the self. This is what leads to the experience of thoughts as percepts, as hallucinations. The voice that condemns or blames the person is a split- off part of the self. This process of splitting of the self can continue until the person’s sense of self has disintegrated. Bion talks of sight and hearing being split off and projected into objects in the environment, inducing the sense of being watched. Another effect of regression is the tendency for the split-off parts of the self to become invaded by archetypical figures (as in Symington’s account). This is really a process of the disintegration of the person. It is important here that this process is seen as motivated despite being ultimately self-defeating. However, one important distinctive factor of this psychodynamic approach is that the process of becoming psychotic is an action of the psychotic person. Much of the symptomatology is a defensive strategy. For Laing, the primary underlying motive is the fear of not existing and the fear of other people because of this primary insecurity. For more traditional Kleinians the fear would be of being destroyed by an external persecutory threat which is the person’s self-destructive feelings externalised (a mirror image of the psychodynamic account of depression as externally directed hostility turned in on the self). However, in both cases the fear of non-existence drives the process. Some clients with “schizophrenia” say that they are dead or that they have killed themselves. He takes this delusion to be a statement of existential fact. Another important feature of this account is that the symptoms occur in response to a central difficulty in relating to others. So it is essentially an interpersonal and emotional problem rather than an information-processing or cognitive model. In Laing’s view, too, the therapy is largely interpersonal and emotional. The key element in allowing the different splits to heal, in allowing integration, is the relationship with the analyst. Laing says that it is the experience of love in the therapy that is curative, if cure is possible. Another important difference here is that all of the symptoms of psychosis are seen as expressions of one process. As the person continues to retreat from other people into a regressed state changes occur to their phenomenology. One important change is the sense of realness or aliveness changes. Both the self and the world begin to feel dead and empty. The person’s ability to reality check is lost as the person loses their communication with the world. During the pre-psychotic state the basic split is between the mind and the body, and the false self is identified with the body, as the real self is experienced as disembodied. Now, as the regression deepens, the person begins to not only feel that their body operates to comply with others’ demands but that their body is experienced as belonging to other people. During the sane phase s/he feels that s/he has false perceptions as s/he is looking through other people’s eyes. However, this leads to the experience that other people are looking through his or her eyes. The person begins to feel alienated from their own thoughts. There is an 94 Part one increasing self-alienation. The initial dissociation from the body deepens and the person feels that their body is someone else’s body. Thought insertion, made feelings and emotions are further examples of this dissociation. Audible thoughts and auditory hallucinations are further examples of this splitting. Bion talks of perception being split off and located in part of the room the person is in. Bollas writes of particular memories being split off and located in particular places, which the person avoids (or which the therapist should try to avoid). Clients with established paranoid delusional symptoms are said to be often protected from the personality disintegration discussed above. It is suggested that the paranoid delusion protects the person from this disintegration, and multiple splitting of the self. Cameron suggests that the delusion is an attempt at restitution of relationships. Now if this is true, then it seems to follow that attempts to alter or challenge the delusion are wrong-headed. One important feature of these various attempts at psychodynamic therapy is that they all emphasise psychosis as fundamentally an emotional disorder and a disorder of relating to others which then results in the catastrophe of personality disintegration. This view seems to be the opposite of that taken by a normalising approach. But these two positions do not have to be incompatible, in that a normalising attitude is quite compatible with seeing the person as having a major handicap in relating to others.

When the sun bursts: psychoanalytic therapy with people with “schizophrenia” The best current account of the application of psychoanalysis to “schizophrenia” is that of Christopher Bollas in his book “When the Sun Bursts” (2015). This is a particularly interesting account, because he has worked extensively with clients with “schizophrenia” and describes interesting modiﬁcation of traditional psychodynamic technique to work with this group. Furthermore, he has worked with clients who are undoubtedly schizophrenic who have not been medicated during therapy. His view is not that there is no place for medication but that for some people medication can simply swap confusion and psychosis for deadened tranquillisation, which is not clearly better that the psychotic state. He does not argue that this is always the case but that it is not always in the interests of the client to be medicated. His theoretical account of the process of “schizophrenia” includes ideas about the psychological meaning of the symptoms but also psychological adaptation to the changed world of the person with “schizophrenia”. He sets out to give a psychoanalytic account of “schizophrenia”. He suggests that no one knows what causes “schizophrenia” but that it is “clearly another way of being human”. What he attempts to do is not give an account of the causes of “schizophrenia” but of the psychological processes involved in “schizophrenia”, of which, he suggests, we know quite a lot. “Schizophrenia” involves a number of processes, all of which perform a defensive function. Why the schizophrenic responds in the way that he does is unclear. Psychotic symptoms have meaning. Furthermore, they are motivated; they are actions. Given this, abolishing the Psychoanalysis 95 symptoms with medication will not be a cure but will lessen the person by alienating them from parts of themselves. Bollas does not mean that medication cannot be helpful but that just abolishing symptoms shouldn’t be the main aim in helping the person with “schizophrenia”, as the symptoms are part of his or her mental life. Just abolishing the symptoms diminishes the person. This way of construing the crisis that is “schizophrenia” places psychotherapy at the centre of the endeavour rather than at the periphery. This is, as anyone who has worked in psychiatric hospitals or in community mental health teams knows, generally the opposite of the current situation. There have been some promising experiments in trying to change this (Laing’s Philadelphia Association and the Soteria project. Both of these projects attempted to put developing a relationship with the psychotic person at the centre of treatment). Bollas describes several features of “schizophrenia” which are either defences against anxiety or consequences of the use of these defences. The transition into psychosis involves a change in the way in which the person thinks, how they relate to reality and the coherence of the self.

Mythology replacing personal history One process that he describes is the production of a personal mythology to replace the person’s actual history. The person who is becoming psychotic is motivated to escape from the ordinary world and their ordinary life and so produces an alternative version of their life. The person is trying to escape from the pain of their current existence, from whatever problems are going on in their life, and forms an alternative mythology. To create this new self the person has to destroy their memories of the past and create new memories, a new mythology. This way of looking at delusions is quite interesting in a number of ways. First, creation of ﬁctional pasts is obviously a question of degree rather than type. We are all aware of how people can recount past events in different ways depending upon their perceived self-interest. Bollas has the psychotic client doing this, except to a high degree. Also, the emphasis on this as a motivated attempt to destroy reality is very different from passive accounts. It is also a different way in which the self is under threat. I had a client who had a serious accident at work which left her unconscious for several hours. She believed that she was to be the Messiah for Europe, and that, Christ-like, she would return and redeem the continent. When we got to talking about whether this was true or whether this was related to the breakdown she had, she said “but someone has to pay”, meaning for the tragedies that had befallen her, prior to her breakdown. Here it seems natural to understand the myth of herself as a hero as an escape from her painful current circumstances. The essential movement is from the pain of the present unhappy life to a grandiose explanation based on a fabrication of the past. This fabrication of a story is obvious once one starts to look for it, but it isn’t really addressed in other explanations of psychosis. It’s not at all clear how a simple biological explanation would ﬁt with this. It is, after all, an actively pursued agenda. 96 Part one

This process is familiar to the cognitive therapist (see Chapter 2, Hazel Nelson’s theory of psychosis); however, there it is background rather than foreground. One feature of the schizophrenic reaction is the replacement of their relationship to their past life with an alternative mythology. This is part of a strategy of withdrawing from everyday existence and contact with others. They (unconsciously) resolve to leave the world of ordinary human experience and they replace it with mythology. This replaces the usual sense of the person being rooted in their past experiences and the normal everyday life with others. This can be on the basis of a fabricated past, or grandiose ideas about the present or themselves. He attributes special meanings to events which others cannot understand. The unconscious aim of this manoeuvre is, Bollas suggests, to avoid the pain associated with ordinary life, and ordinary interactions with other people. The invented past may not always be a positive invented past, but at least it avoids the pain of real life. In part, this process may be because something has happened to the person that makes them unable to integrate their personal history, and in part because it avoids the pain of thinking about their past. In addition, the continuing experiencing of hallucination directly impacts on the person’s sense of connection to the real world.

Schizophrenic transcendence The schizophrenic person rises above to an alternative reality. Often the mythical story that the client tells us will relate to key memories in the person’s life. The schizophrenic person transcends the pain in their life and the catastrophe of their breakdown to an alternative reality. This reality is not without pain but its essential beneﬁt is that it provides a way of structuring events in time. This alternative reality is, in part, the delusional system. Sometimes this is a system in which there is a denial of pain. Bollas notes that some clients with “schizophrenia” move in and out of this mythical way of understanding their life. Sometimes the alternative itself seems full of pain. To believe like one of my clients that you were to be kidnapped and tortured to death seems on the face of it entirely negative. The transcendence provides a structure for past and future. Bollas suggests that often the transcendent myth includes symbolised references to real problems, events and traumas. Understanding what is stored in these myths is important to the therapeutic work. Bollas says that the myths of the psychotic patient are “profound dreams”. For example, the client who believed that she would be kidnapped and tortured to death believed that as a teenager she had mistreated her parents by being delinquent and getting involved in drug-taking and promiscuity.

Communion with the thingness of the world People with “schizophrenia” relate to objects in the world rather than relating to people. Usually we are connected to others by our converging narratives. The launch into the mythical world distances us further from others. Bollas acknowledges, however, that part of this difﬁculty in constructing a historical story about oneself Psychoanalysis 97 may be that the mind has lost its ability to do this, in addition to avoiding pain. Usually we are connected to one another through the collective unconscious, he suggests. There is nothing very mystical about this idea. He means that in the groups we live in we have shared underlying assumptions and ways of being in the world. Being part of a family or other group we are connected to each other. As the schizophrenic loses his or her personal history they connect more to things than to people. The perception that the person is in some way absent to family and friends or workers follows from the attempt by the person to get rid of their own personhood. Mechanical movements are part of the same pattern. At the same time as the person begins to make himself less human he also begins to animate the inanimate world. They may hear rocks or stones talking to them. Or fear that inanimate objects will begin to move. This is brought about by projection of parts of the self into the inanimate world. The person feels threatened by contact with people and also by the strange change that has occurred to him or to the world. In order to protect himself he projects parts of himself into objects for, as it were, safe keeping. But this projection is not purely an imaginary phenomenon. The effect, for example, of this projection on the person is real. He really does become depleted of parts of himself. He projects out his intelligence or his anger and this really leaves him feeling depleted. And this effect is noticed by other people. Following Bion, Bollas suggests that the faculty of perception can be projected out into the object world too, and this can be one source of the sense of persecution. Bollas suggests that the sense that objects might become animated can be communicated to the therapist, who might start to worry about objects in the room beginning to move. Another possibility he mentions is that staff around chronically psychotic patients can become overly calm and passive. He suggests that this is a way of staff trying to make themselves unthreatening to the patient. He says that it may take years to get to the point where one can start to discuss this process with the client. The belief that nature may become animate is an example of what Bollas terms “the unthought known”, i.e. tacit knowledge. (The therapist can act here as a type of “transitional object” from inanimate nature and real, live, terrifying human beings.) By splitting and projecting out on a massive scale the person is rendered a caricature of their former self. They can move in a robotic manner, their gestures can become mechanical. They can lose the central self which is the originator for action. Furthermore, the psychotic person approaches objects as if they are animated. Here it seems that it is not the aim of the patient to render themselves robotic, rather it is the aim to expel bad parts of the self, and this projection is what leaves the ego massively depleted. He is describing a state which is reminiscent of Frith’s account of the loss of metacognition leading to volition, and what the general psychiatrist calls “negative symptoms”. For Bollas, this state is not aimed at but is the result of a defensive action. A schizophrenic atmosphere is produced that infects the therapist, who can begin to worry about his safety in ordinary situations, or on the contrary feel particularly relaxed. One of the aims of this projection of parts of the self is to keep it safe from being destroyed. 98 Part one

Belief that objects are asleep As the person begins to feel more and more dead because they have projected their feelings and parts of themselves into the environment, they also begin to feel that inanimate objects are alive but asleep and might awaken. One aim of therapy is to persuade the client over time that the therapist is actually a safe person.

Metasexuality Another way in which schizophrenics distance themselves from the raw human contact is through what he refers to as “metasexuality”. By the prefix “meta” in this case he does not mean “referring to” or “about” but “beyond sexuality”. For non- analysts, this type of explanation can easily mislead. Bollas is talking about the diver- sion of sexual energy into all relationships, towards all people and also towards ideas and inanimate objects. And the idea is that this is partly to avoid the acknowledge- ment of difference between the sexes or between the generations. It is to avoid triangulation. But all of this is supposed to be carried on unconsciously and without arousing any specifically sexual feelings. One could ask in what way these are still sexual feelings. Maybe what is being talked about is the avoidance of any special relationships. Everyone is the same. So this “metasexuality” is actually another path to avoid the painfulness of human relationships. Bollas suggests that the onset of “schizophrenia” in adolescence or shortly after adolescence is related to the crisis of moving from childhood to adulthood, in that same way that anorexia can be. However, I think that the idea can be rescued from libido-theory implications. His hypothesis is that the person abolishes personal relationships in favour of an impersonal relationship to the non-human. The aim of this, as in all dynamic accounts, is to avoid pain. This regressive (i.e. back to early stages of infantile mentality) process causes the person to experience the breakthrough of intense infantile forms of perception. Colours are brighter. Fantasy is prominent. The person creates a self from the imagined power of this situation. He now finds himself as a lone person in the world and he begins to fear that, as he has destroyed the objects in the world, if he cannot be omnipotent then he may be attacked. This is one of the processes that leads to fearing being attacked or destroyed. This is narcissistic in that the person is relating to himself in a variety of guises. It is an image of early mental states as an hallucinogenic trip. Of course this hypothesis, if taken as a statement about the mental states of infants, has no real evidence for it. It is a specu- lation based on understanding these changed states of consciousness in adults as regression in the sense of going back to a former time. The other sense of regression, i.e. entering a more primitive state of mental organisation, is clearly a different matter. It is this that analysts have evidence for derived from encounters during psychotherapy. Bollas suggests that relating to others through “metasexuality” leads to believing that he or she has superpowers. Transcending the human limits of difference (difference between parents and children, between male and female, between animate and inanimate) leads to a sense of omnipotence. So the motivated retreat from human contact because of the anxieties produced leads to a denial of Psychoanalysis 99 differences and relating at a higher undifferentiated level. This is felt as conquering the challenges of reality, and that leads to a sense of all-powerfulness, which is one of the sources of delusional ideas. This feeling is, however, felt to be fragile and this leads to the person feeling that he is in danger of falling to pieces, feeling alone in a world that he has harmed and which is out for revenge. The person’s delusional ideas and feelings are, then, in this account, secondary to a retreat from relations with real people. This means that they have achieved a victory over the bonds and limits of a real, live relationship but at a cost. This sets up the atmosphere for the development of delusion, but the delusion is a symptom of the underlying causally generative problem. When a client feels that people are spying on him wherever he goes and that everyone is involved in the conspiracy this is a symptom of a changed way of relating. He is not conscious of this prior change, as he does not report it. The evidence for the change is in the delusion but also in the poverty of his relationships. An alternative explanation of his changed relationships might be that he retreats from relationships because of his paranoid delusions rather than the other way around. Here the difference between the accounts is probably ultimately not simply to be settled in terms of the evidence. We have two different underlying models. So the person with “schizophrenia” is avoiding relationships and the feelings associated with relationships by relating to all equally, and to preference relating to things rather than people. The primary defence mechanisms are splitting and projection. Feelings are split; love and hate, and the idea of the person that the client is relating to is split into good and bad. Furthermore, whole mental faculties such as reasoning and sight are projected into objects, and this is the origin of the feelings of being watched. Melanie Klein talks of projecting into the other person, but Bollas argues that people with “schizophrenia” are too afraid of retaliation to project into people and so project into objects. However, in therapy, people with “schizophrenia” do sometimes project into other people or the therapist. One client I had was sure that the security lights that went on in the house across the road to her were actually being directed at her and came on at particular times to send a message to her. But it was the people in the house that she felt were setting the light up to do this to her. Bollas (and in this he is following the usual psychodynamic thinking) argues that this flight from relationships also involves a regression to more primitive ways of thinking and feeling and perceiving. The unconscious with its radically different way of thinking is breaking through, and this leads to some of the early psychotic experiences of changed perceptions –colours brightening or sounds seeming louder, for example (Chapman and Chapman, 1988). Also, thinking is organised according to the primitive principles of the unconscious association and superficial sensory similarity, rather than logic or abstract meaning. The changed thinking of the psychotic is just the thinking of the unconscious, which is why psychosis reminds us of dreaming. This breakthrough of a regressed, primitive form of thought, which is usually only glimpsed at in dreams (or possibly in myths), is a chief characteristic of psychosis. This model is a combination of motivation (to avoid contact, to get rid of thinking as defensive moves) and a regression to a different form of consciousness, 100 Part one which presumably is not just about motivation but also a feature of this different type of thinking. He argues that in triumphing over sexuality the schizophrenic person feels connected to objects in a higher way; connected to mental objects. But this leads to him feeling that he has murdered his mother and father. The result of this is that he finds himself alone and feels threatened for having committed murder. So when he hears voices or encounters objects he assumes that he is about to be destroyed for his crimes. This can produce agitation or catatonia as a protection against this mania. This account explains the sense of persecution or of being conspired against as resulting from a sense of guilt rather than being an explanation derived from experiences (as in the Maher’s account).

Causes and effects of hearing voices Hearing voices occurs in the context of the unconscious relation to the world that has been described above. He has an abiding fear that the inanimate world can be awakened and that this would be bad news. This underlying feeling is, of course, a radically changed assumption about the world, although assumption is probably not at all the right description, as it sounds far too deliberate. It is a changed way of being in the world. We don’t conclude that certain things are animate and others are inanimate from first principles, rather we bring that way of relating to the world along. Bollas understands voices as aspects of the self. The “sense of self” is still retained in “schizophrenia”, he says, but it is altered. It has lost some of its agency, or “sense of freedom”. It is like a distant reporter on events and actions rather than being involved. He suggests that at the beginning the person’s voices come from inanimate objects but later become disconnected from objects and come from the person’s mind. If he means this as a general rule and if he means this as a conscious phenomenon then it is not clear that this is the case. We do not see clients at the beginning of their psychosis but they often report not knowing where the voices are coming from at the beginning. Evelyn Waugh’s (1957) narrator in “The Ordeal of Gilbert Pinfold” reports hearing the voice out of nowhere and concluding that it must have come from a radio in the ceiling in the cabin of the boat, because he could not localise it, and this is a common report. One client told me that when he first heard the voices, he assumed that they were coming from outside his house and that someone was hiding outside his window. When he says that after a time the voices speak from inside the client’s mind this needs some clarification. If he means that after time the person experiences the voices as coming from his mind this cannot mean that the person locates the voices in a particular place, because the mind is not a particular place. For example, the self is not identified with the brain or head. This can be seen easily from the reports that voices are coming from inside a person’s head but are someone else’s voice. If it means that the person realises that the voice is a part of their mind this is not true, in that many chronically psychotic people have no insight into the origins of their voices. Some people do say that they experience their thoughts as voices, but now realise that they are coming from their Psychoanalysis 101 mind, are part of their psychology, in the same way that in dreaming we can experience sights and sounds but realise on waking that these are produced by our mind, but this certainly doesn’t happen in all cases. In any case, he suggests that the voices are parts of the person’s self. The voices can be a set of independent personalities. He likens this state to the state in childhood in which children treat inanimate objects as having personalities and befriend them. He sees this as part of the changed schizophrenic world. However, the schizophrenic perceives this change in the object world as menacing rather than as friendly. Fearing that he is in danger from the object world in some way he protects parts of himself by projecting them into objects. The voices represent the way in which the person has related to him- or herself throughout his or her life. So the voices personify a way of self-relation that has existed before. They may also be associated with particular experiences that the person has had. By being expelled they stop being part of the person’s history, so that when they return they seem to come from outside the person. To return to my client Jill (discussed above), who was persecuted by visions and voices of the man who had sexually abused her. She believed that these voices and visions were Satanists (although they didn’t really appear to be human; I don’t think that she was really clear about this, and that is quite typical of clients’ feelings about their voices or delusions). In my client’s case, however, it seems easy to see how they represented a traumatic memory (having been repeatedly sexually abused) and also a part of her (a voice which condemned her and told her she was to blame and was worthless and deserved to die). It doesn’t seem obvious, however, how this worked as a defence against these feelings, i.e. how it gets rid of these feelings, as she still felt that she was to blame and deserved to die, and she also still remembered the events. This seems closer to an expression of these attitudes and memories rather than an expulsion. Analysts do, however, talk about these defences aiming to expel certain feelings but failing. Bollas explains friendly voices as valued parts of the self which have been projected out. He says that some of the aggression of voices can be to do with resentment about being ignored and not listened to. This really does seem to be treating the voices as sub-personalities, rather than as perceived sub-personalities. In “The Internal Family and the Facts of Life”, Deborah Steiner uses the idea of inner sub-personalities to explain two clients’ breakdowns and their attempts to recover. As discussed above this idea is in Freud’s “Mourning and Melancholia”, in which Freud explains melancholic depression as the result of this type of internalisation. Freud says that depression resembles grief in all respects except that in depres- sive states the person is highly self-critical and can become self-destructive and suicidal. He says that depression is precipitated by a loss and that if one examines the complaints that the depressed person makes about themselves these complaints actually fit the character of the person who has been lost rather than the depressed person. He explains this in the following way: to avoid the loss the person internalises the lost person so that the self-criticisms are actually criticisms against the lost person. Part of the person’s personality becomes like the lost person. The person is identified with the lost person. Freud’s idea of the superego is also the idea of a sub-personality 102 Part one in the self. As discussed elsewhere this idea was derived from Freud’s observation of clients with delusions of being spied on. He thought of this as being a separate part of the self which sits in judgement on the person’s actions. So in psychosis, according to Jung or to Bollas or to Symington, the voices that the person is hearing are the voices of split-off sub-personalities. During his Tavistock lectures in the 1930s, Jung was asked what the difference was between these split-off sub-personalities in psychosis and those of dissociative states (at the time classified as hysteria, but now probably mainly classified as borderline personality disorder). Jung said that it was the degree of dissociation that made the difference. That is a difference in degree not in kind. Today’s biological psychiatry argues that the voices are different in kind, and will often try to suggest qualitative differences. I used to think that I was missing something about the nature of the voices and visions that people reported, but now I think that the quality of the voices is perceived as different by the psychiatrist after the diagnosis has been decided on other grounds (such as problems with anger, history of abuse or neglect, being surrounded by conflict in central relationships, for example). The voices in psychosis mirror the way in which the person has talked to themselves throughout their life. The motive for projecting these parts of the self into objects or the world is to stop them from being a part of the person’s history. Positive parts of the person are projected to preserve them. Bollas argues that really the psychotic viewpoint on this is actually closer to reality than our usual idea that we are a unified “self”. Here is an interesting case of normalisation, where the psychotic perspective contains a truth not seen in non-psychotic states of mind. This particular point (although not his general depiction of “schizophrenia”) is reminiscent of Laing’s thesis about psychosis in the Politics of Experience. The effect of this experience is that the person begins to experience his or her mental life as an observer rather than as a participant. This experience begins to make the person feel alienated from the real world. The sense of self that we have of our being-in-the-world is affected by this. The person is increasingly dominated by their relationship to their voices. This leads him or her to become scared of losing his or her mind. A related change is that symbols begin to be taken for the things that are signified. In interactions with others, voices make it difficult to concentrate on what is being said. Originally the person begins to feel all-powerful. When the person stops believing this they begin to feel in danger of being persecuted by all-powerful forces that surround them.

Hearing voices The person with “schizophrenia” has anxiety about waking inanimate objects. People with “schizophrenia” do not lose a “sense of self”, but rather have a sense of themselves as drastically changed. The relationship between the “mind” and the “self” has altered. He suggests that the person has a robotic feel about themselves. They feel less free about their actions; rather, the person reports on herself like a distant reporter. Hearing voices comes from this experience of alienation from Psychoanalysis 103 oneself. This comes from projecting out parts of oneself into the environment and the unconscious breaking through into awareness of primitive unconscious thinking. Bollas understands verbal hallucinations as occurring in this context. He suggests that at ﬁrst voices are heard coming from inanimate objects; a rock might speak. Over time the voices become disconnected from objects and speak from inside the patient’s mind. The voices can be a set of voices with independent personalities. This is similar to the way in which children will take inanimate objects as friends to relate to. Relating to objects, animating them and hearing them speak and the increased vividness of colours are all part of the same process. The schizophrenic is seeing/relating to the world as a child. The difference is that the schizophrenic does not see the world as benign. Her fear of this animated world makes her withdraw and this makes her project parts of herself into objects human, animal and inanimate. Delusions of persecution come from her split-off and projected hostility. Sometimes she can project parts of herself to save them from being destroyed.

Psychotherapy for “schizophrenia” Hanna Segal and Norman Cameron both carried out psychoanalysis with clients with “schizophrenia”, and both maintained that it was unnecessary to alter the basic technique. It is hard to imagine, however, many clients with “schizophrenia” tolerating the blank slate approach to therapy combined with only interpretations, if for no other reason than if the client does not consciously see himself as ill but rather as victimised why would they want to engage in this therapy? Bollas, from his personal experience of applying psychoanalysis to this group of clients, indeed suggests a number of technical alterations. First he says that the technique required varies depending on whether someone has just had a breakdown or if it has been some time. If someone is in the midst of a breakdown, he suggests, the important task is to engage in a conversation about what has just happened to them. The person will not have developed defensive ideas about the process, so a more direct approach is helpful. Reconstructing the events that have led up to the crisis is in order. He believes that he has prevented people from developing “schizophrenia” on the basis of this early intervention work. However, if it has been some time since the onset of the crisis, he uses a different technique. A direct approach is usually not possible, as the person will feel attached to the strategies that they have adopted to prevent them from the fear of the destruction of their mind (unconsciously – that is, this is not a calculated strategy).

Restoration of historicity Taking a history has the function of restoring the “narrative function of the self”. The schizophrenic client has replaced his life with a myth (for example, the delusional system that the person has created). This can be to escape the pain of their own story, but other factors can also be involved. One task of the therapist is to re-establish the historical narrative of the person’s life, so reconstructing what the 104 Part one person has actually done. One client of mine had started to believe that his grandfather had had contact with gangsters who had been recruited to control or punish his father. His family denied this because he had come to believe they had had their memories interfered with by the gangsters. Here, then, is this client’s myth. It contained in it some truth (his father and grandfather had had a difﬁcult, acrimonious relationship and at times this had become violent). In this case the myth is more about the family and he is less in the centre of this myth than is usually the case with delusions. However, this interference in his parents’ lives and memories also impacted on him, because one of the effects of this interference had to do with his feelings for a former therapist. This had been managed in accordance with the needs of the gangsters. Being interested in the details of his actual personal history, the mundane facts of where he had gone to school and what work he had done began to re-establish his real life story. If psychosis is a retreat from life this is a move back towards reality.

Not reasoning about voices Bollas argues that as the voices that the person hears are actually part of his or her mind which have been split off and projected (dissociated if you prefer), arguing with the voices isn’t going to work. Here is an important difference in the therapeutic implications of this model to that of CBT. There is no point arguing with yourself. He suggests that it is better to listen to what each voice says and to try to understand what its motives are. He suggests the therapist ask for details about the voice and for the client’s associations to the voice and what it says. As the voice can’t elaborate on what it means this leaves the therapist and the client discussing the voice and its meaning and intention. This discussion undermines the authoritative position of the voice. Rather than the voice issuing pronouncements, it is being considered and thought about.

Strengthening the “I” As the central problem for the schizophrenic is the disintegration of the self, Bollas argues that the process of free associating and talking is in itself helpful, as it strengthens the self. That is, giving the person space to talk about their hopes and fears, the events of the week and the past – in short, allowing the person to talk and helping them to clarify their feelings. He says that simply talking for oneself is therapeutic, as it strengthens the illusion of a single uniﬁed self. He means by this that in many ways the schizophrenic perception of a fragmented self is nearer to the truth than the illusion of unity that goes along with sanity. Since much of the problem comes from this fragmentation into pieces, this talking for oneself is helpful.

Very early psychosis A different method is needed if the person has an established psychosis rather than if they are being seen immediately after the breakdown. If the breakdown has Psychoanalysis 105 occurred very recently, then asking for a detailed account of recent traumatic events can help to process these events and, he suggests, this can reverse the psychotic process. Obviously this is a difﬁcult hypothesis to prove on the basis of clinical observation, as we don’t know what would have happened in the counterfactual situation where we didn’t intervene, but it is his clinical observation that with clients at the beginning of a psychosis this can be reversed. The unity of the self can be strengthened and further splitting minimised. At this point the person will usually want to talk and understand what has happened to them. Once a psychosis is established, however, and he is talking about weeks rather than months, the person will actively defend their interpretation of events and want to avoid thoughts, as these will be felt to be dangerous.

Bringing a third object into the room Contemporary psychodynamic technique focuses on interpreting the client’s unconscious feelings towards the therapist. David Malan describes a system for describing the interpretations that are made in therapy and describes a triangle of person; the therapist, past attachment figures and current attachment figure. Interpretations of hidden feelings can be made linking any two of these figures. He says that much counselling links past to present relationships but that the distinguishing feature of psychodynamic therapy is the linking of the therapist to other figures. In general, the interpretations which are thought to be most important are those which concern the therapist-client relationship. Hanna Segal and Norman Cameron suggest that it is possible to use this technique with clients with “schizophrenia”. Although this might be possible, it seems very unlikely that this technique could be used with many clients with severe symptoms. This is because without any insight and with defensiveness about the state of his mind it is difficult to imagine the client engaging in this process. As discussed above, the psychotic person will feel threatened by attempts to take away his new world or introduce thoughts. The goal here should be to ease the defences against the fear of being overwhelmed. Bollas has altered the traditional method. He calls this alteration “bringing a third object into the room”, and by this he means bringing another topic into the room. He might talk about current affairs, or a film or a TV show. The difference here is that the analyst is introducing a neutral topic as a way of allowing the client to hear the therapist before they are able to talk themselves. To anyone who has worked in a more supportive way with clients with psychosis, or indeed any other serious psychological problem, this may appear to be obvious, but to anyone who has experienced psychodynamic therapy it is a large shift. The intention is still to develop a psychotherapeutic conversation, but the therapist has to take responsibility for beginning the conversation to demonstrate, by action as it were, that the client is safe. After some time the client will become curious about the therapist, about his life and character, and the relationship can begin to be built up. I think that the point here is that any comment or interpretation of the client’s mind at this point 106 Part one is in danger of being perceived as a dangerous intrusion. The point here is to establish that the client is safe. A very similar process happens in the early stages of cognitive therapy (albeit, with a different language to explain this). A long period of engagement is suggested. Nelson suggests that it is particularly helpful to make clients tea and be interested in any neutral topic they bring. Bollas goes further in introducing topics of conversation. These suggestions are quite liberating in that a keen therapist may feel that in order to see them as working they should be doing something active, and ironically this can be the least therapeutic thing to be doing. Here it can be seen that the length of treatment is going to make a difference to the type of treatment that one is doing. If one is really going to limit oneself to six sessions, then this period of gaining the trust of the client will not be able to develop. I have found that clients actually vary a good deal in the length of time that it takes to establish a rapport. But you can never be sure. I had been seeing one client for 18 months in his own home, for a cognitive therapy. He had long-standing delusions about the government spying on him and him being monitored. His parents had been involved in a paramilitary organisation and he had memories of the house being raided and his father arrested as a small child. When I went to see him at home he quickly began to engage in conversations about his life and his voices. After 18 months he told me that at first he had been sure that I had been sent by the government to spy on him. I asked him why he had agreed to talking to me in that case and he said that he had done that so that he could keep an eye on me. So Bollas suggests that it is important for the therapist to be active and to begin the relationship with the client. The client will start to be interested in the nature of the therapist, and this is encouraged as a way of developing the relationship, without the client feeling threatened. Eventually he begins to make interpretations. He suggests that at first these should be about episodes in the therapy when there is a lack of rapport, so talking to the client about times when the client feels distant from the therapist or that the therapist has misunderstood the client.

Respecting voices Bollas suggests that given the voices are actually a disavowed part of the person’s mind, it is important to treat the voices with respect and to try to work out what they are trying to say or achieve. One is reminded of voice dialogue work, where the person is encouraged to carry out a dialogue with their voices, in which the aim of the voices is discovered to be other than purely malice. When I have tried carrying out a voice dialogue with clients I have not found that they discover a less punitive motive behind the apparent sadism of the voices, but other workers have. As mentioned above, he suggests that one engage with the client in a conversation about the purposes and intentions of the voices, as the voices cannot speak for themselves. This puts the client in the position of being an observer of their own psychological processes. Psychoanalysis 107

Tolerating projections When the client projects into the therapist, for example in seeing the therapist as stupid or untrustworthy, it is important to tolerate being used in this way rather rejecting the interpretation or interpreting it to the client.

Avoiding triggering projections Certain memories or feelings can be projected into various places in the present or in the past. Asking the client to talk about these times or places can trigger over- whelming feelings, so in reconstructing the person’s narrative it is better to try to avoid this if possible. Bollas’ account of therapy with a client with “schizophrenia” comes from his psychodynamic understanding of the problem, but it involves much in the way of technique that would be found in other psychotherapies with this population. I will discuss this further in the ﬁnal chapter.

Similarities and differences One attraction of Laing’s account is his description of the psychological factors leading up to the psychotic breakdown. There is nothing similar to this in Bollas, whose story begins with the beginning of the breakdown. As Laing describes this process, there is a continuum of withdrawal and this is based on an early development of a particular kind of psychological vulnerability – only feeling precariously attached to the world and his or her own body as part of this. On the other hand the transformation from sanity to madness in both cases consists of a regression to a different, more primitive form of thinking. Once the psychosis has occurred, Laing’s account is similar to Klein’s account, or Cameron’s account. Laing’s account is an existential-phenomenological account, so he is concerned to explain and justify the schizoid experience of the world, often in terms of a change in phenomenology, but the transition to psychosis involves a recognisably psychoanalytic description of regression. Cameron focuses on the development of a delusional state as a consequence of trying to reduce the anxiety that the person feels about his or her increasing feelings of persecution. His account of the development of the feelings of persecution is similar to that of Laing. Bollas, too, regards the formation of delusions as anxiety reducing. However, he emphasises the person as escaping from pain –pain whose source may be in his or her life, or which may be from his or her mental state. Laing points out that insanity is only one of the possible outcomes for the schizoid state. However, he doesn’t really explain why in one case this might happen and in other cases it would not. 108 Part one

What can we learn from a psychodynamic account? One of the most useful things that this type of account can add to cognitive therapies for psychosis is a way of thinking about the person’s symptoms which explains them as actions rather than as simple occurrences. We may also be able to use counter-transference in cognitive therapy of psychosis, and in general being aware of the nature of the relationship with the client can help us to guide the therapy. For example, Bollas talks about how the client’s projections can make the therapist anxious or bored. The therapist may feel that they are sitting with someone who does not relate to them as a person or who can make no sense of their internal world. Thinking about this in the context of the client’s prevailing problem can help to understand the position of the client and to not act out with the client, by going along with the idea that the person has, for example, no feelings or that his or her beliefs are, for example, ridiculous. A major difference between cognitive and psychodynamic accounts is accounting for particular symptoms versus accounting for a syndrome. Looking at the syndrome rather than the individual symptom has the advantage that gestalt psychology always claimed over behavioural psychology of the sum being more than its parts. So if we focus purely on voices or delusions we may miss the link between the different symptoms and the meaning of the symptoms in the crisis that is the psychotic break. Thinking of psychosis as an action rather than as something which is a happenstance is another important idea. Thinking about psychosis as a motivated retreat from reality is a hypothesis which will be more obvious from a dynamic perspective. Bollas makes several changes to the usual analytic stance and some of these technical changes could helpfully be incorporated into a CBT therapy; for example, strengthening the person’s connection to his or her historical narrative by asking about and recounting different parts of the story and thinking about the person’s withdrawal from others. Trying to reconstruct the development of the psychosis and how this ﬁtted into the person’s life are obviously helpful in seeing the person as having had a personal catastrophe rather than an organic illness. PART TWO

7 APPLICATIONS

In Against Method Paul Feyerabend (2010) argues that the theoretical models of science can lead to dogmatism rather than empiricism. He suggests that once we have a theory in mind we can become blind to certain facts and force them to fit in the procrustean bed of our model. He gives several examples of how the progression of science depended on ignoring an apparent contradiction between a new finding and other already established findings. For example, it was argued against Galileo that if the Earth were moving then objects falling from a height should describe a curved line rather than falling to a point directly below where they are dropped. Galileo had no way of explaining this at the time. Feyerabend suggests that the principle of conservatism, whereby new evidence needs to be particularly striking in order to alter a well-established theory, seems to give undue preference to an idea that is already established. He suggests that we should adopt what has been described as an anarchistic attitude towards theory and practice in science. Applying this to the current issue would be to move towards an eclectic approach to theory and practice in working psychologically with psychotic clients. This is not a matter of being technically eclectic but being open to the relevance of different psychological theories rather than fitting the person into the model. As well as problems with hallucinations and delusions, psychotic clients also present with difficulties in relating to others and integrating their own feelings and thoughts. In this they are not alone, of course, but the degree of alienation from themselves and/or from others is more extreme. This causes problems for the therapist, who wants to talk with the person about their feelings and thoughts. What is a thought or a feeling and what is a fact can be a contentious issue. If it is possible, linking the person’s breakdown to the circumstances which were occurring at the time in his life is an important strategy. How important depends on how recently the person broke down. 112 Part two

Cognitive therapy has been very important in re-establishing the role of talking therapies with people with psychosis. The focus on single symptoms was an important part of this development. Paul Chadwick’s work on delusions, for example, and Slade and Bentall’s work on auditory hallucinations made the idea of a therapy more achievable. Helping someone to rethink their ideas about a delusion or to develop coping skills to deal with hallucinations are less intimidating goals for a therapist than trying to cure “schizophrenia”. It may be, however, that something is also lost in taking a single symptom approach. Many of the attempts to conceptualise “schizophrenia” as a disorder have addressed the loss of integration in the personality, or the loss of self as a central theme. Although the cognitive neuropsychology of Frith or Hoffman and the psychoanalytic approach of Laing or Bollas are very different accounts, they do have in common the idea that in “schizophrenia” some central difﬁculty in self-integration is lost. A lot of cognitive therapy in the 1990s began with work with paranoid patients with chronic delusions. Traditionally, this group of clients has been seen as having relatively intact personalities, the hypothesis being that a systematised delusion protects the person from the disintegration of the personality. This may also have affected the cognitive model of psychosis. Paranoid patients will often identify their sole problem as the people behind the conspiracy against them.

Implications If there is some truth in the idea that in “schizophrenia” or in psychosis in general there is a loss of self or a loss of contact with reality, there are a number of possible implications for cognitive therapy with these clients. If we take the problem as being not the psychotic symptoms but the underlying causes of the symptoms in the personality this will inﬂuence how we work with these clients considerably.

Reconstructing a narrative One of the amendments that Bollas makes to traditional psychoanalytic technique with schizophrenic patients is the attempt to re-establish links with the person’s actual biography. This, of course, is derived from the idea that psychosis is a regression from reality, an avoidance of relationships with others. This model states that psychosis is a regression, that the psychotic person is in a changed state of consciousness akin to dreaming and that this is a motivated change. That the person is retreat- ing in this way is fundamental to understanding the analytic approach. The central idea or metaphor in cognitive therapy is that the person is making some kind of mistake. These different basic ideas lead to differences in approach to intervention. This is why Bollas is drawn to a reconstruction of the person’s past and the events leading up to the onset of the psychosis in particular, in so far as it can be tolerated. This seems a promising addition to the techniques used in CBT with psychosis. Or maybe it would be better to express this by saying that it would be a useful addition to the approach to the client in cognitive-behavioural therapy for psychosis, to try to reconnect people with their actual lives at present and in the past as a way of weakening the power of a delusional system. I had a client who had been a Applications 113 schoolteacher in Sydney until she had a paranoid psychosis in midlife and had to retire. The precipitating event seems to have been the pressure of the school inspec- tions, and the end of a relationship she had been in for several years a little time before this. She left work. Her explanation of what happened to her was that she had a brief sexual encounter with an actor. She only met him on one occasion but then she began to believe that he was being prevented from seeing her by a number of people who wanted to prevent her from having a relationship with him. Everywhere she went she would interpret events in line with this belief. At one point I began to talk about the idea of testing out whether this belief was true and she went off and set up her own experiment which demonstrated to her that she was indeed correct in her beliefs. The difficulty was that everything that she came across had a changed meaning that fitted in with her delusional system, so it was difficult to get any point of external purchase on her ideas. She believed when she went into a pub that all the people in the pub knew about her and that they were communicating about her to each other, and that they were part of a conspiracy to stop her meeting this actor. One could say that this is an example of a self-esteem generating delusion and that she might have much invested in the truth of this delusion, because in reality she no longer had a job or a partner. So if the belief were true there is the possibility of hope (that she will eventually meet up with her man) but if the belief is not true this possibility is no longer there. This seems to be true. And in addition the evidence for the belief was slippery as much of it depended on how she interpreted neutral events. In this case, working on trying to reconstruct the events of her actual life in the past and present could have been a useful strategy. She had, really, a lot invested in her delusional world, so reconnection could be a way of moving away from this. This is different to the encouragement to engage in occupational therapy or other aspects of psychiatric rehabilitation, because it is attempting to reorient the person’s thinking about themselves back to reality. If we think about the person’s alienation from their life as a central problem, rather than the delusion or hallucination, we are likely to respond to them differently. Coming back to the agenda to work on her delusion (which was actually my agenda and not hers in any case) was always like pushing a car uphill, whereas allowing the client to go in whatever direction they choose frees us up from this sort of problem. Paul Chadwick’s idea of being radically collaborative is in line with this approach to some degree, although Chadwick is suggesting following whatever goal the client has whereas this approach is different in that it would involve not having any goal at all. The lack of a goal and following the client wherever their associations take them can be an active attempt to understand and emphasise with the world as seen by them. This may mean tolerating seemingly random associations rather than insisting on bringing the client back to logical, sane discourse.

Interpreting the motivation of the voices Arieti’s suggestion that prior to hearing voices a person is expecting to hear voices and that monitoring this can generate insight into the nature of voices would be easy to incorporate into a cognitive therapy. 114 Part two

Taking the person’s voices or the characters in the person’s delusions to be aspects of the mind of the person can lead to attempts to understand the motives of the voices (i.e. the person’s motives that have been projected into the voices). This is similar to but a little different from Chadwick’s role-playing with voices using the gestalt technique of talking to an empty chair, and Birchwood’s method of confronting voices. It is different in that the therapist can wonder with the healthy part of the client what the motives of the voices might be. Bollas gives the example of a voice which was telling the client that he smelt and should set ﬁre to his workplace. Bollas wondered with the client about why the voice might be suggesting that he set a ﬁre and suggested that it might be in order to cook for his colleagues in order to socialise with them.

Understanding the person’s psychosis psychologically Another way in which these ideas can be useful is for the therapist to be thinking about the person with a psychological view of the psychosis in mind.

Counter-transference Tracking one’s own feelings towards the client can be very helpful; in particular, if one has negative feelings about the client or if it is particularly difﬁcult to relate to the client. Laing suggests that the crucial therapeutic ingredient in therapy is to love the client. This, of course, is not always possible, but thinking through one’s own negative responses may be crucial.

1. Bear in mind the totality of problems the client is bringing, both acknowledged and unacknowledged. If the person presents complaining about hearing voices this will mean putting the voice-hearing in its interpersonal perspective and thinking about the role of the voices in the person’s mind. What is the person’s interpersonal life like? How do they relate to themselves? 2. If psychosis involves a loss of self then practices to build the self up will be a good goal. Lysaker’s metacognitive therapy aims at this and in a less structured way a lot of Bollas’ additions to technique do as well. So, for example, strengthening the “I” by encouraging the person to relate their story becomes an active technique. 3. Listening to the psychotic myth and thinking about this without feeling the need to comment on it is helpful and is similar to the long period of engagement in CBT but with a different purpose. 4. Reconstruct the person’s historical narrative, at the appropriate time, with the aim of connecting the person to their real life and, through that, others’ lives. 5. Think about delusions and hallucinations as projections and think with the person about why and what. What are the voices trying to do? 6. Think about one’s own feelings about the person. Develop a real bond with the person. How does the counter-transference ﬁt with the person’s problems? 7. Be aware of the psychological catastrophe which has overtaken the person. Applications 115

Case studies The cases I will present are largely clients who have long-standing delusion. Sometimes these have been developed into alternative world views (by which I mean becoming general explanations of more or less everything that happens) and sometimes they haven’t. Sometimes the delusional viewpoint waxes and wanes depending often on environmental stresses. Over the longer term broader factors than symptoms are inevitably involved. Beyond the psychotic story the person brings along the problems that they have in general in life, which is sometimes symbolised in the psychotic symptoms.

Sue Sue was a 40-year-old woman who lived in a privately owned house in Hackney. Her parents owned the house and the family was middle class, with her father still working as an accountant in the city. I began to see Sue for therapy as the last in a long chain of therapists. Recently, she had been seeing a psychologist in the acute team and they had referred her on for longer therapy. It was thought that a male psychologist would be better, as she had developed delusional ideas about a former female therapist. Sue had emerged from childhood as a slightly isolated figure. She had one or two brief relationships with boys but she had failed to establish a long term relationship. She had been bullied in school and at technical college and had had few friends. When she came for therapy she saw only two friends, and she didn’t see them very often. She lived near her parents. She came to therapy after having had a psychotic breakdown and being admitted to hospital. She had started to have delusional memories. Her main problem was OCD, however. She complained of cleaning and checking compulsions and of intrusive images during sexual activity which she had to repeat to neutralise the effect of the image. She lived near her parents and had returned to studying at university. She explained that her delusional symptoms had started when she was under stress. She began to remember that a local policeman had come to her school to ask her about an incident of domestic violence at her home. Her childhood had been unhappy. Her grandparents had lived with her parents and there had been a lot of conflict between them. She told me this story after we had been meeting for a month or so. She began by telling me that she was going to tell me something that she had never told a psychologist before. She then told me that she remembered an occasion in which the conflict between her parents had reached a high pitch and then they had come to blows. Her father had knocked down her mother and kept beating her. This had happened when she was about 7. As an adult she had begun working in an office and she discovered that a co-worker was related to police officers. The co-worker had had to leave work after a serious assault. When she developed a psychosis she began to believe that the police-officer father of this colleague had come to her school to question her about the violence between her parents. This became a delusional memory. The two incidents of violence in people she knew had been 116 Part two joined. When her parents denied that this man had had contact with them she began to believe that the secret service had interfered with their memories in some way, which led her to descend into madness. The main change prior to her breakdown was beginning a new term at university in which she was taking subjects which were more difficult and which she had great difficulty comprehending. Throughout her life she had had difficulties in relating to others and she had few friends. She told me that at this time she had always wanted to have a boyfriend, and to have children. However, she had little luck in her attempts to meet boys. She was also bullied at school and later at technical college. She found this very upsetting. When she raised it with the college the student claimed that she was joking, and in the end she withdrew from the course. After this she formed a close attachment to a young female social worker who she began to see. She saw her for several years. She had suggested that she was trying too intensely to find a boyfriend and that she should concentrate on developing a career and that if she did this the relationship would follow. She took this advice on board in a major way, stopped worrying about going out with boys and concentrated on work. This was also the stimulus in going back to university later on. So taking the degree would, she felt, fix her psychological problems, give her a career and also give her the opportunity to develop friendships and find a boyfriend. In short she felt that the degree would fix her life. She had few friends and put her hopes into the degree as her route to salvation. Thus the meaning of finding she could not cope with the content of the academic work was catastrophic. She wasn’t really aware of any of this; we pieced this together during a series of conversations in therapy, which was a year later. I saw the transition into psychosis as a reaction to her perception that she had failed in all her important goals in one fell swoop. The content of her delusions took several real events (the cruelty and unremitting conflict in her family, the work colleague’s assault and the feeling that something was going terribly wrong in her life) and expressed them in the way that a dream might do. In this context she began to feel that there was a danger outside. Maybe the security services or maybe the good therapist turned bad were conspiring against her. She began to think that the security services were interfering with the memories of her parents. What she didn’t tell me was that she had also believed that her old therapist was behind this conspiracy to affect the memories of her family and cover up the incident. It seems most likely that this explanation is driven by her feelings of grief and hopelessness rather than by a primary problem with understanding other minds, or through a miscalculation of the evidence. After all, she had been understanding people’s intentions more or less all her life, and she recovered from the breakdown to the same level of understanding. The cognitive-neuropsychological explanations don’t really lend themselves to explaining this type of breakdown (time limited in response to a massive loss). One could argue that this type of persecutory delusion was a different type of persecutory delusion based on diagnosis. But the quality and content is the same and really it would be necessary to have evidence for such a claim. On the other hand she had long-standing problems with relationships with people, and this is missed if one focuses only on the overt psychotic symptoms. Applications 117

Some of these difficulties can be seen as theory of mind deficits. She would often get annoyed by something that her parents said or did and be unable to drop the issue until she had obtained an apology and there was something that was quite controlling about this. In sessions with me a number of patterns emerged. Often reorganising appointments was difficult. I felt that any reorganisation was perceived by her as a difficulty, and this reflected rigidity in the way that she carried out her relationships with people. She had two friends that she saw regularly, one a woman she had known for many years. A disagreement over a small matter erupted into a texting fight in which she said some very unpleasant things about her. Later she regretted the comments she had made, and a part of her thought she could have a relationship with her, but she was unable to find a way of talking about this with her. I thought this reflected her experience of relationships always in conflict as a child, and that this might be why she found it difficult to maintain contact with people. She idealised her previous therapist, although she had seen many psychologists since then. She would talk about the relationship she had with her as superior to all the other psychologists she had seen (including me). Another characteristic of our sessions was that we alternated between discussing her obsessional symptoms and her more general life problems. She wanted to talk about her symptoms, but this did not help. But if we talked about her life she found this depressing. Her obsessions did interfere with her life in a moderate way. Her rituals would not take much time, but if she found she was in the grip of an obsession she would find she could not concentrate on study, and she would worry about this when under pressure (which often became a self-fulfilling prophecy). The underlying fear with her obsessions was that someone would be hurt in some unspecified way if she did not carry out the ritual. If she thought unacceptable thoughts she had to undo the thoughts because if she didn’t she would feel contaminated by the unclean thought. The obsessions and rituals defended against a sense of danger from some unclear place. When psychotic the fear was of an external person or thing. The fear is of something outside, and of course one main difference is that she no longer thought that the fear was irrational. The development of the delusion can be thought of along Maherian lines. She has as a sense that there is a plot. When she tries to check the evidence for the plot and it is disconfirmed she alters the theory to accom- modate the evidence. But her reason for doing this in this case seems clearly to be because of a strong feeling of fear that the theory rationalises. This process is also described by Bollas and Cameron. What seems common to these accounts is that the delusion serves to reduce anxiety and is therefore actively defended. Although she has difficulties in understanding other people’s motives (or maybe in relating to other people) this cannot explain the regression into and her coming out of psychosis. It seems that in this case this is a regression which has followed on from feeling that her hopes in her life had fallen apart. The delusion in this case links two incidents with similar content and then turns them into a threat, but the elaboration is where the beginning of madness truly begins. Before her psychosis Sue’s situation could be described as a conflict played out between two sub-personalities. A critical aggressive part of her was monitoring her 118 Part two thoughts and feelings in order to prevent something dangerous occurring from her actions, thoughts or feelings. A judgemental sub-personality was set against a judged or victim part of her personality. This role combination “Aggressor versus Victim” was probably learnt from her experiences with her family. This could be played out with other people. When she argued with one of her friends she ended up destroying the relationship, as she rejected playing the role of the victim, and took on the role of the aggressor. When she became psychotic the critical aggressive part of her was externalised. She saw threat and danger coming from others. This is an example of what is meant by the breakdown of the “boundary of the self”. The threat now comes not from a sub-personality of her mind but from outside. A policeman has been investigating violence in her home. The secret services or her old therapist are conspiring against her and have altered the memories of her parents. Where does this radical hypothesis come from? Is it a failure of the ability to read minds? And if so why such an elaborate hypothesis? Or is it the example of a different type of thinking (dream thinking, associative thinking) dominating her conscious thinking. It isn’t obviously a logical error. If it were a dream we would understand it. There is a threat to her central life goal which is perceived as a conspiracy against her, and this explanation serves to reduce her anxiety. It may also be that here there is a change in the phenomenology of her world, as Jaspers states and Laing and Bollas would suggest. This is more obvious in more disorganised states of mind. but it may be that the delusional system here is partly motivated by the fear of things falling to pieces. A changed threatening meaning may lie behind these beliefs in a conspiracy. She is also withdrawing from the world of people. This was helpful to hold in mind when working with her. Of course there would have been little point in saying any of this, as it wouldn’t have made any sense to her and she was motivated to not think about any of this. But holding this in mind helped to orient myself to her and her problems. I worked with her on her OCD but I also began to piece together the story of her life and to think with her about what it had been like for her, without ever trying to talk about her psychosis in these terms. I became increasingly aware that although she could succeed academically, in many ways she was rather lost in her life. But this was the end point of a long process of not being able to interact and relate to other people. Towards the end of our sessions she began to talk about how her attempts to fix her life by studying and following the advice of her previous, idealised therapist had failed. She had felt that if she followed the advice of the previous therapist things would work out. As I said, the sessions more or less alternated between discussing her obsessions and her life. I think it was important to allow her to take the sessions where she would. Insisting on discussing, for example, symptoms would have driven her reflections on her sad, lonely situation in life underground. In this therapy she knew that she had been psychotic, so it was easier to engage her in therapy. There were no active psychotic symptoms. Her presenting problem was anxiety. However, when I talked to her about the personal issues that seemed related to her breakdown, she became depressed. She had invested hope in the idea that getting a degree would solve her life’s problems. This was tied up with the Applications 119 positive transference she had to her first psychologist. If she got the degree she could be like her. I felt that she felt that if she got the degree she could be fused with the previous psychologist. When we discussed any of this she became depressed and at the next session would want to talk about her symptoms. In this case, because the psychosis is time limited and involves a transition into and out of a delusional state, explanations in terms of an information processing disorder do not fit easily. Viewing the response as a regression has the advantage of linking her problems in growing up with her current problems in life and makes the psychotic transformation meaningful and understandable. I think that despite the depression the therapy helped in strengthening her authentic self, strengthening the “I” by allowing her to talk. I also thought that although more depressed she was more in contact with her own personal history.

Tom Tom is a man in his mid forties who I saw for therapy for some eight years. He lived in Romford, East London. At the beginning his diagnosis was “schizo-affective disorder” but he had also been diagnosed with “schizophrenia” at some point in his life. He had a chronic paranoid delusion, but he also related to people and the real world, so his investment in the delusion varied. When he had his first breakdown he had delusions in which he believed that he had a special purpose to redeem the world and he believed that everything around him contained signs and messages. He came from a middle class family and he was a second generation immigrant, his family having immigrated to the UK from Uganda in the 1970s. His family valued education and his mother was a teacher. He became ill at the age of 16. When he was about 10 he moved schools to be at a more local school. The next couple of years of his life appeared to me to be really important in understanding how his life developed, but he only told me about what happened much later in therapy. He had changed schools mid year but everyone had their own friendship group and for a year he was quite alone at school with no friends to spend time with. Furthermore, he became the object of bullying from some of the other children in the class. One particular boy singled him out for repeated emotional abuse. His appearance was mocked and his isolation was also mocked by this particular boy. During graduation, this boy offered Tom an award for “the largest nose”. (Years later this boy met Tom in an admission ward and continued the castigation.) At the time, Tom felt that this must mean something about him. He must be unacceptable or unlikeable in some way. After two years this bullying was ameliorated, however. He began to mature and became attractive to the opposite sex, and this began to make him more attractive as a friend. Also the classes were split so that rather than one form (in which he had had the role of the outcast) there were a number of different classes in which he could play different roles. He became popular with the girls at school, which boosted his self-esteem, but the girls that he started to date also began to have a negative influence on his self-image. He had been dating a couple of young women and looking back on these experiences he regarded them 120 Part two as empty and that they were not really interested in him but had been using him. He began to become increasingly suspicious about their motives and this progressed into increasingly threatening fears. He began to think that one of his girlfriends wanted him to be involved in prostitution. He had dabbled in magic in a small way in the past. He had cast a few spells, without being seriously interested in the occult in any way. Now he began to be worried about black magic. He felt under threat wherever he went. He said that looking back on this time he was living in a different world where the meaning of everything had changed. He was admitted to hospital and attempted to hang himself. He began to experience signs which related to him wherever he went. After he was discharged he had to leave school and he completed his exams by studying at home and returning to take the exam papers. He was referred to me 12 years later following an admission to hospital after attempting to kill himself with carbon monoxide in his car. He was always taking courses and when I met him he was struggling to complete the final placement of a social work degree. He believed that people were conspiring to expose him as a fraud and to expose him on TV. Various things counted as evidence that this was happening. He saw birds around the window of a neighbour and became convinced that the neighbour was a witch. He often interpreted things that happened in line with his suspicions. He felt that when he went for a job interview the interviewer had decided that he wouldn’t get the job before he was interviewed. This made him think that people were communicating about him to each other. One time when he arrived to see me he told me that he thought that I had spoken to one of the nurses about him. There was a nurse in the Hackney hospital where I saw him who had been involved in the church that he used to go to. He wondered if I had spoken to her. He began to believe that people in his church were talking about him. One of the prevailing themes was that people would talk about the fact that he owned a house and wonder how he afforded it, especially as he was in receipt of benefits. He worried that people would think that as he had no physical problems and wasn’t disabled that he had no need of benefit and was therefore a fraud. He worried that people were keeping him under surveillance to prove that he was a fraud and that eventually he would be exposed as part of a documentary on TV. On one occasion he had received a parcel in the post which was addressed to “Mr Cheater”. He felt sure that this must have been sent to him deliberately as a threat or warning that he was a cheat and a fraud. When he talked to people at his church he worried that they would find out that he had his own house and would think this meant he was dishonestly claiming benefit. He had a number of friends and was often studying university courses in fine art. When he had close contact with people who were not his close friends for any lengthy period of time he would begin to become suspicious about them. For example, when he was studying an art degree he began to think that some of the students were talking about him behind his back, and overheard conversations would be understood by him as referring to him. I began by using cognitive techniques with him. I began to explore alternative explanations for his experiences with him. Applications 121

Often there would be the opportunity to carry out natural predictions about what might happen. So, for example, when he believed that he had failed an interview because the interviewer had clearly been biased against him I talked with him about possible alternative explanations apart from his belief that he was being conspired against. A week later when he was offered the job this “behavioural experiment” was evidence that he had been biased in his initial interpretation. The sessions were largely characterised by his narrating in great detail the events of the week. Often this left little room for a conversation about the significance of these events. I think that this was probably because he had a great need to communicate with someone and that by this being a monologue he could have control over the contact, and keep it safe. In the initial six months most of the sessions were focussed on reality testing his delusional beliefs, and this had some impact on how firmly they were held. Actually, we revisited these beliefs throughout the therapy and in particular when he was in crisis or under stress, or when something unusual or unexpected happened. I tried to talk to him about his filling up the sessions with stories. The sheer volume of what he discussed made it difficult for me to focus clearly on what he was saying. When I discussed this with him he tried to focus more on particular items and took, at one point, to making lists, a bit like I had done during the first phase of therapy. At one point we changed the frequency of the sessions from once a week to once a fortnight and this put increased pressure on the space in the sessions. After a few years of therapy he began to talk in detail about his experiences of having being sexually abused as a child by an adult friend of the family, and also later as a young man. He had been raped by an older cousin when he was a very young child. His parents had dealt with this effectively by his account. When they had discovered that he had been assaulted they spoke to the perpetrator and ensured that he never met him again. This experience had set up a fear and distrust of people and in particular in a close relationship. After the disastrous relationships of his teens he avoided relationships throughout his twenties and into his thirties. He also talked with some guilt about how these early experiences had sexualised him and how he had upset younger friends with his sexual advances. When he talked about this he became guiltier and began to feel more persecuted. He described avoiding driving near the home of one of the girls whom he thought held a grudge against him because of his sexual behaviour towards her. In his case it is true that the cognitive processes of confirmatory bias and selective attention can be seen to be at work. However, it also seems that his delusions of persecution are an expression of his feelings of guilt, or are related to his feelings of guilt. The content of the sessions was this sense of filling up the space, but I came to think that this was less about obliterating the object (i.e. me) out of envy or fear but more about desperation for contact. (Albeit, rather one sided contact, as my efforts to join in the conversation were often in vain.) However, when I moved workplaces he continued to see me in my new workplace, which required considerable effort on his part, so I was in no doubt that he valued the sessions. He was always hoping to meet the right woman, but never seemed to find anyone who was interested in him which he put down to his height. Yet when he did meet someone who clearly was interested in 122 Part two him he became fearful about pursuing the relationship. At other times, when, for example, someone contacted him on the internet who had no friends listed, he showed a lack of protective suspicion, so I began to get quite direct in telling him that I thought he should be careful about how he approached this possible relationship. In the therapy I think he had the contact that he wished for but in a controlled way. It seems possible that he unconsciously set up an atmosphere which conveyed that he was fearful of relationships, although consciously he disavowed this. When an old work colleague asked him to come for coffee he assumed that this was a date. It turned out that this was an attempt to get him involved in a selling chain. She had said, “You know that this is about more than the product.” He took this as a hint that she was interested in him. When a neighbour left pornographic magazines out with the rubbish he thought that this was aimed at him. If I asked him how strongly he believed that he was being conspired against he would have different ratings at different times, and his belief responded to cognitive challenges, at least in the short term. The most traumatic thing about his sexual abuse was his precocious sexual behaviour that resulted from the abuse. He felt very guilty about this. From the beginning he was very engaged in the sessions. He saw me as a helpful, benign presence. His parents had been very supportive to him. He had a younger brother. Sometimes his parents argued and he worried about them breaking up. In the past when his parents had been fighting his father had got drunk and he had been scared of how his father was acting. In his twenties he had decided to avoid relationships, as they didn’t seem to work out well for him. There was a contrast between the way he saw me (as a benign, helpful figure) and his feelings about most of the people he had related to in his personal life. I thought that his way of handling the sessions was to fill the space up, so that it was a one-way relationship. I did wonder if this was to keep me from becoming a dangerous figure, as if the benign nature of the relationship was rather thin and might at any moment change into something more threatening, but I had no evidence for this hypothesis (apart from the history). When he was first psychotic he had believed that he had influence through magic. When I was seeing him he had an underlying belief that he might be being conspired against and exposed as a financial fraud. But occasionally other ideas were around, so he wondered if a neighbour was a witch. He saw meaning in a lot of circumstantial coincidence. One way of thinking about this is that his delusional system defended him from his experiences of being lost in a confusing world of not knowing what was him and what was not him. Another way of thinking about this is that he was experiencing a phenomenological change of the type described by Bollas (and also Jaspers). On this account, his ideas of having magical powers reflect a prior change in which he had begun to experience inanimate objects as alive and the world to operate by magical rules. In thinking about his reaction to the trauma in his life it is clear that the delusional beliefs mirror some of the feelings of danger, threat and guilt which are all part of the experience of child abuse. But what about his early experience of finding the world full of hidden meanings and self-reference? He told me that when he first Applications 123 became psychotic these experiences filled up his whole life, so that, in his words, he was “living in a different world”. Here the cognitive model has little to say about how to understand why he was having these experiences. These experiences can be seen as part of a regression to a different, more primitive way of thinking, reminiscent of dreaming and linking by association. Laing at one point thought that psychosis was a process aimed at healing a person living in an unliveable situation. It was over two years before he began to talk about his experiences of abuse. Could this have been speeded up by bringing this up earlier in the therapy and, so to speak, driving the agenda? I think that the most important part of this therapy was establishing a relationship with the client where he felt cared about and therefore able to bring up these feelings. I think this meant being able to allow him time to feel safe before bringing up these feelings, and to talk through concerns that came up about me in the course of the treatment. Coming up with more benign interpretations of the various difficulties that beset him was part of this process. Tolerating projections was important. In the therapy I felt that he projected into me a benign presence. This was, I felt, one of the reasons why it was important for him that I should be mainly a listening figure. I felt that if I was too active in the sessions he felt intruded upon. He had several friends whom he saw regularly, and he also had frequent contact with his parents and sister. Throughout the therapy he was continually trying to engage in courses. Throughout this he carried a low level of paranoia. This would not be obvious to casual observation. However, once he had been at a workplace for some time he would begin to become more suspicious about the other people he had to interact with. At one point he had begun a course at a technical college. At first this was fine but within a month he had begun to think that people were talking about him behind his back. He would think that overheard conversations related to him and that comments had a hidden meaning relating to him. This resulted in him withdrawing from the course. This was also true of his situation at work. At church he gradually came to believe that he was being talked about behind his back, and he had been quite heavily involved in the church for several years. He had friendships with people which he had maintained over many years. There is a similarity here in his experiences at school (when he was ostracised and bullied) and his experiences later. In the therapy the repeated challenging of his beliefs was helpful, albeit over several years rather than a few weeks. I had the impression that by repeated revalu- ation of the evidence that he was being conspired against he began to internalise this particular function. He internalised the role of the empirical critic asking, “What would be another explanation for these experiences?” In the transference I became an idealised figure. One issue here is whether to challenge this perception from the client or not. Hanna Segal stresses the importance of interpreting the negative transference. She says that not doing so will mean that the client’s relationships with significant others in her life will deteriorate – that is, that while the therapist is idealised others will be denigrated. Tom idealised me while keeping me at a distance and flooding the sessions with accounts of his current problems or achievements. 124 Part two

This did not seem to lead to him becoming more paranoid about other people, however. He had generally good relationships with his relatives. One important part of the therapy seems to me to have been the establishment of a relationship in which it was possible to talk about these issues without being dismissed, i.e. a close conﬁding relationship. Connecting to his personal history involved discussing his complicated feelings about being abused, and how this had sexualised him, but he also eventually talked about some negative experiences with his parents. I think that this connecting with reality probably did help him to distance himself from the alternative, mythical version of his life (i.e. the delusional story). It is hard for me not to see his psychotic experiences as expressions of his life problems expressed through a regression. It was also helpful as the therapist to try to understand his current experiences. Thinking of the people who he felt were talking about him or conspiring against him as parts of him was helpful to me to continue to be in a therapeutic state of mind. His suspicion was trying to keep him safe from being attacked, as was his avoidance of relationships. Or the conspiracy explained his sense of anxiety and foreboding and helped him to avoid fears of being swallowed up by his world. After several years he did begin dating, which he had not done since his teens and which did seem like some progress.

Jane Jane was referred to me in her late twenties. She had a chronic paranoid delusion which had a major impact on her life. She had grown up in Dagenham in Greater London but her parents moved to the country when she was a teenager, and she hated this and felt she didn’t fit in. It had been hard to make friends. She was full of regrets about her childhood. She had begun using drugs and not working at school. She told me that she remembered a key event from her late teens. She had stolen some drugs from a dealer that she knew. When he was asleep she had gone to his house and taken the drugs home. She felt that a lot of the bad things that happened to her had happened as a result of this event. She also felt that being involved in drugs and not working at school had been very bad. She felt that she was being punished as a result of this. She had a diagnosis of “schizophrenia” and she was on Clozapine, which had made her put on a lot of weight. She didn’t think that she had a mental illness. She had trained as a veterinary nurse but had not been able to work in this field for some years, mainly due to feeling intensely paranoid when at work. If she was around people, then everything seemed to have a hidden, persecutory meaning. Even when not working she felt that she was being conspired against by a gang who were going to kidnap her and persecute her for the incident in her past. It was a bit unclear how she had worked out that this was happening, but she was convinced that she was being persecuted by things that happened to her on a daily basis. Most of these things involved her thinking that events occurred which related to her in a special way. For example, she would hear cars backfiring in her street or hear fireworks being detonated. She would be sure that these were Applications 125 messages directed at her. I saw her in therapy for about eight years. It was clear that she became aware of these coincidences when she was under more stress and when there were anniversaries or other significant dates. When she was in her twenties she had a job working as a nurse and her employer’s son had unfortunately died of a physical illness. She felt that this had happened because the gang were taking revenge on her. She lived with her mother and father and disabled brother. She was involved with caring for her brother. When she was under stress she would interpret what her brother said as having double meanings. When she was under stress she became increasingly aware of apparent coincidences. Her fear of reprisal would be heightened at any possible anniversary. Christmas, New Year, her birthday and the end of the tax year all filled her with dread. She began to tell me that the room that I saw her in was bugged and had cameras in it. She also told me that she thought that I had been told to encourage her to talk about her personal life so that they could find out about her. I was puzzled and asked her why in that case she came and talked to me. She said that actually she couldn’t get away from them wherever she went, so that she would be no better off if she didn’t come to talk. At other times though, we could examine the likelihood that these ideas were true and she could look at them with some perspective. The thing that seemed most helpful with her was not to examine the evidence that the beliefs were true or false, but to examine the details of the events surrounding her paranoid experience. So, for example, apart from anniversaries she would become more suspicious when she was under more stress. So reviewing the recent events in her life when she was feeling more paranoid would often relieve some of her fear and reduce her paranoid ideas. Why did this help? I think that this may have been a version of Bollas’ method of reconnecting a person to the real story of their life. The paranoid narrative is one version of a life and if one goes down that path it becomes self-reinforcing, so merely relating a paranoid experience to the events of her real life served to pull her back from the paranoid alternative version of her life. Her experience of me in therapy was, I think, a good example of “double book- keeping”, as suggested by Sass and Parnas (2003) (and also in “The Divided Self” (Laing)). When she told me that she thought that I had been told to draw her out in the sessions so that the gangsters could hear what she was thinking she didn’t say this with any sense of resentment or anxiety towards me, and she would continue to talk about her problems with me in a confiding way. I thought of her feeling that everywhere was bugged and she was never safe as a change in her basic relationship to the world rather than a conclusion based on evidence. This made me less inclined to think that I should try to change her belief about this and more to validate her feelings or to bear witness to her experience so that she felt less alone.

Fred Fred was a man of 35 years who lived in an industrial area of Kent. His family were from Pakistan but he had been born in England. He had lived with his parents all 126 Part two his life and had a difficult relationship with them. He had a lot of resentment about how they had treated him when he was younger, and expressed this in aggression towards them. He usually presented as overwhelmed by his emotions, acting impulsively or self-harming or having assaulted his parents. Or he would be worrying about some life problem. However, occasionally he would become convinced that he was the subject of a conspiracy or that there were references to him on the television. He had been given a number of different diagnoses including “schizophrenia”, “schizo-affective disorder”, “bi-polar disorder” and “borderline personality disorder”. He was his parent’s only child. When he was 12 his father had to give up his job due to illness. He sank into unhappiness and began to drink to cope. His mother was at work so he began to spend more time with his father, who became increasingly unhappy and abusive. He would criticise him and call him names. Many years later I witnessed this first hand when his father came to a joint session and screamed insults at him. He felt quite lonely as a child. He had found it difficult to make friends at school. He felt pushed around and badly treated by friends that he did have. It was around this time that his father became abusive towards him. His parents separated when he was 15 (several years later they got back together) and he felt left alone to cope with his father. At school he found it hard to fit in. He felt different to the others at school and that he did things that made him stand out as different. He began to have girlfriends but most of these relationships ended very quickly. He told me that as soon as he got the feeling that his girlfriends might be changing their feelings he would dump them, so that it would be him that left rather than them. Although most of the time he presented as having problems with impulsivity, with instability of emotions and with his identity, he also had periods of frank psychosis. He had multiple admissions to hospital, usually following an overdose or a threatened overdose, but sometimes when he had paranoid delusions. During periods of stress he used to develop paranoid ideas. Prior to one admission he had been in a part of East London which had a high Islamic population. He began to be terrified that he would be abducted by ISIS. This feeling persisted, however, when he got home and continued for several weeks. He didn’t have any insight into this at the time. He was admitted to hospital and these ideas persisted. Psychiatrists who met him in this period were sure that he had “schizophrenia”. People that knew him for a long period didn’t share this opinion. He was a good example of how the categorical diagnostic system doesn’t really fit the facts of everyday clinical observation (Ross, 2000). As well as some people insisting that he must have a psychotic illness, others would insist that he must be faking his symptoms. So the environment in hospital which had originally felt to him like a safe haven and a retreat from his difficulties at home began to feel unsafe and persecuting. It didn’t ever seem very likely that he was inventing his symptoms if one watched him carefully. When the television was on in the main sitting room he would choose to go and sit outside in the cold and gloom because he experienced delusions of reference when he watched TV. If there was any report of a crime on the news he would become convinced that he had committed the crime. References Applications 127 to unsolved murders (which seemed to be on the news quite a bit of the time during his stay in Hackney hospital) would always result in him remembering things that might implicate him in the crime. He would experience paranoid delusions and delusions of reference. He put pressure on me as the therapist, testing the limits by doing provocative things in the sessions. The focus of my work with him was on maintaining a working therapy. I didn’t work on the fleeting psychotic symptoms at all. It was important not to be pushed into reacting to the client or to ignore his aggression. I set various goals with him, none of which was very helpful, because the goals were like a moving target. Although he didn’t have chronic psychotic experiences his lack of a sense of himself as a person and his sense of desperately wanting to find somewhere to fit in is reminiscent of Laing’s ontological insecurity. His problem, seen in this way, is that he is trying to find confirmation of himself existing as a person, and that the fear of being left, and fury at the possibility of rejection, comes from this. The psychotic episodes then become an extension of this way of relating to the world and himself, rather than an additional unrelated problem.

Henry I saw Henry for therapy over a five year period. He was in his forties. He lived in a council house in Hackney and had lived his whole life in that area. He had a long- standing diagnosis of “schizophrenia” and had had these symptoms since his late teens. He had been a troubled teenager and had felt that he wasn’t really wanted by his parents. He absconded from school and acted out in a variety of ways. He had few friends and had behaved in a variety of mildly antisocial ways. He had set fires and spent many days truanting on his own. He didn’t feel that he fitted in at school and was happy going off on his own. When he got distressed he used to cut himself. He had been neglected and abused. He remembered his grandparents encouraging him to drink when he was still a child. He remembered his father as violent and his mother as uninvolved. He felt that his older brother had always been his mother’s favourite. He remembered hallucinating from a young age. As an adult he had begun to hear voice and see visions. He had worked in a clerical capacity as a young man but had given up this work and married an older woman when he was in his early twenties. They didn’t have any children. His wife was twenty years older than him. When he was referred to me his wife was very ill and he had moved back in with his mother. He found his mother demanding and critical. He felt that his siblings were always favoured. He had lost his driving licence after falling asleep at the wheel and following this he had managed to stop taking Valium, which he had been addicted to for many years. He had visual hallucinations and heard voices, although he didn’t talk about these experiences very often. He told me that he could communicate with people telepathically. He believed that he had come from Mars, and although the details of how this had happened and how he knew this were a little vague to me he was certain of this, and there was nothing metaphorical about his belief. 128 Part two

These beliefs did not feature much in the therapy, however, as they were not his most pressing concerns. A major concern (and the reason that he was referred) was his suicidality. Indeed, after we had been meeting for about six months he spent six months in hospital due to these feelings. I remember quite distinctly early on in his therapy getting a call from him early on a Sunday morning. I was at the time in the middle of making breakfast and I was not at all sure why I was receiving the call. He began to talk of the beauty of the sun on the sea and the glistening of the waves. At some point in this description I realised that he was calling me while standing at the top of a cliff looking down at the sea and across into the sky. I said that I thought that he should turn around, go to the bus stop and call me again when he got home. Which fortunately he did. This feeling of suicidality seemed to come from a feeling of disconnection from his world. He lost his wife (with whom he had a fairly ambivalent relationship) shortly after this. After she died he found that he missed her much more than he would have thought while she was alive. He did have visual hallucinations of his wife, which disturbed him. He also had times when he would be out at a shopping centre and would feel that everyone could read his mind (that is from his point of view he knew that everyone could read his mind). But he didn’t act on these experiences in the way that one might expect given his certainty that they were real. He had two views on the visions of his wife and I couldn’t quite work out what he believed. He thought that he saw her, not a ghost or a spirit but her, alive. But he also knew that she was dead. He knew these things were the case, but couldn’t explain how this could be. I think it is possible to understand his feelings of his wife being alive and dead at the same time and feeling that he is literally from Mars as a primary change in his phenomenology rather than a deduction from any evidence. It is a bit like being lost in a dream. Also this experience occurs in someone who has only made a tenuous connection to other people, Laing’s idea of a someone not experiencing themselves as fully, tangibly alive. At the beginning of the therapy I was concerned with behavioural strategies to lift his mood, as indeed were the various other mental health workers whom he came across. It was striking how many of the various case managers, nurses and social workers that he came across seemed to really engage with him. Workers would offer to help him outside of their usual hours of work and he struck up a friendship with several of these workers which carried on after they had stopped working with him in their professional roles. I tried various strategies to help him in the first year but then began to focus on thinking about what he brought along as issues and trying to help him think through what might be going on. What he brought was nothing very psychotic, because although he did have psychotic experiences he did have continuing relationships with people, and on a one to one basis he was able to engage with people, and people were clearly able to engage with him. Here it is relevant that although he had many negative feelings about his late wife he had continued in their relationship. In his sessions with me he talked about his various conflicts with her family and with some of his mental health workers. In the transference I was idealised, but this didn’t seem to be a particularly destructive process. I thought that maybe it was quite Applications 129 helpful for him to be able to have a good figure in his life, especially as most of the people in his family seemed to let him down in some way. He did talk negatively about a lot of the other people he saw, but it would have seemed unhelpful to insist on talking about negativity in our relationship. It did, however, come up. During one session I had been finding it difficult to focus on what he had been saying. We discussed his feelings about the session and he had noticed that I had seemed less attentive. This was the beginning of being able to talk more about our relationship, and hence his feeling of being cared for or neglected. His trauma history was evident in his everyday encounters. I think that the therapy didn’t focus on the symptoms of “schizophrenia”, as he had other things to bring. Often when someone only brings symptoms it is because they don’t have other relationships to bring along. The symptoms may become the focus of a person’s world when there is little else to be involved with. But certainly it would have been really unhelpful to try to focus on these symptoms. And in his case it took a year before we really settled down to a stable counselling relationship, so a brief therapy would not really have been of much relevance. In some ways it seems that what is most important is not so much the severity of the paranoid beliefs and persecutory hallucinations but the degree of positive engagement with other people. And although he used to like to retreat from the world to his own room in the house in the afternoon and felt most at ease when he did not have to engage with others, he still did engage with them. Therapy was one place where this engagement could be developed and thought about. He became very keen on coming along to the sessions and I often heard that everyone else in his life was letting him down except me. I did try to talk about this with him but it didn’t change the idealisation. I think that he found it helpful to feel that someone was on his side. REFERENCES

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A-B-C (Antecedent, Belief and Bion, W. R. 82, 85, 86, 93, 94, 97 Consequence) model 11–12, 23 bi-polar disorder: and psychoanalysis 79 amphetamines 7 Birchwood, M. 10, 11–12, 13, 18, 20, 114 Anscombe, G. 74 Blake, William: “Ghost of a ﬂea” anti-psychotic medication 7, 8 painting 40 anxiety disorders: continuum and Bleuler, E. 21 normalising approach to therapy 25–6 Bollas, Christopher: cause of schizophrenia applications see therapeutic applications 4; compared with Laing and Cameron archetypes 87, 93; see also collective 107; dreams and psychosis 99, 112; unconscious and Jane case study 125; metasexuality Arieti, S. 87–8, 113 98–100; model of “schizophrenia” 77–8, association: complexes of associations 87; 94–5; personal mythology 95–6; free association 68, 78, 87, 104; as projection into objects 96–8, 99–100; process of thought 21; and unconscious psychotherapeutic approach 103–7, 108, 81; word association tests 87 112, 114; regression 98, 99–100, 112; Austin, S. V. 9 self-integration issues 112; splitting of autism 46 memories 94; and Sue case study 117, 118; and Tom case study 122; Bak, M. 29–30 transcendence 96; unconscious 99; Baron-Cohen, S. 46 voice hearing 100–3, 104, 106, 114; Bateman, A. W. 20 When the Sun Bursts 5, 94 Beck, Aaron 23, 42 borderline personality disorder 26–8 being-in-the-world 89, 97, 100, 102 Brentano, Franz 46 beliefs: A-B-C (Antecedent, Belief and Breuer, Joseph 78 Consequence) model 11–12, 23; vs brief psychotic disorders: and borderline delusions 33, 35–6; delusions as normal personality disorder 26–8 beliefs 8–11; vs imagination 69–70; British Empiricists 21, 58 metacognitive beliefs 20, 53 Byrne, S. 18 Bem, Daryl J. 38 Bennett, M. R. 73 Cameron, Norman: paranoid psychosis Bentall, Richard 52–3, 112 model 77, 79–80, 84–5, 94, 107; Bentley, G. E. Jr. 40 psychotherapeutic technique 103, biological theories 7–8, 24 105; and Sue case study 117 136 Index

Campbell, John 65–8 continuum theory 25–6, 27, 28, 29, 39, 41 case studies 5, 115; Fred 125–7; Henry conversion experiences 36–8 127–9; Jane 124–5; Sue 115–19; coping enhancement therapy 19 Tom 119–24 coping strategies 12 Chadwick, Paul D.: cognitive therapy Cotard’s delusion 42, 55, 68–9 and work on delusions 112; cognitive counter-transference 108, 114 therapy model (with Birchwood and Currie, Gregory 69, 70 Trower) 11–12, 18, 23; cognitive therapy treatment duration 10; Davidson, Donald 5 collaborative relationship 11–12, 16, De Jong, S. 22 113; delusional beliefs study (with delusions: vs beliefs 33, 35–6; Cotard’s Lowe) 9, 10, 11; role-playing with delusion 42, 55, 68–9; delusion-like voices 19, 114; stress/PTSD and ideas vs delusions proper (Jaspers) 56–8, psychotic experiences 17 59–60; in general population 29–32, Chestnut Lodge hospital (USA) 7 33; and imagination 69–71; and childhood autism 46 metasexuality (Bollas) 98–100; as childhood trauma: and borderline normal beliefs 8–11; of reference 35, 45, personality disorder 26 61, 85, 88; SCAN criteria 30–1; Cognitive behavioural therapy for psychosis and sub-personalities (Jung) 87; and (CBTp): chapter overview 4; command superego 80; see also hallucinations; hallucinations 18–20; delusions as normal paranoia; voice hearing beliefs and development of CBTp 8–11; Dennett, D. 49, 51, 54 dominance of biochemical theory up to depression: in analytic theory 80; see also 1980s 7–8, 24; duration of therapy 20; melancholia first models of cognitive therapy 11–16; Descartes, René 35, 57, 67, 91 Metacognitive and Reflective Insight direct perception of meaning 58, 59–62 Therapy (MERIT) 20–3, 114; person- dogmatism: vs empiricism 3, 111 centred cognitive therapy for distressing “double booking” 125 psychosis 16–18; therapy vs psychological dreams: compared to psychosis (Bollas) 99, explanation of psychosis 23–4; see also 112; and sub-personalities (Jung) 87; as therapeutic applications type of imagery 69–70; and unconscious cognitive dissonance: and obsessional (Freud) 81 thoughts 54; and self-deception 14 DSM (Diagnostic and Statistical Manual of cognitive neuropsychology of Mental Disorders) 21, 27, 28, 59 “schizophrenia”: chapter overview 4–5; Frith’s theory 5, 21, 42–7, 48, 50, 51, early maladaptive schemas, theory of 16–17 53; Hoffman’s theory 5, 42, 47–52, 53; efference copy 44, 49, 66, 67, 70 Morrison, Bentall and source monitoring ego: in analytic theory 80; in Jung’s theory 87 52–4; use and limitations of approach Eigen psychosis 30 5–6; see also therapeutic applications Ellis, Albert 11, 23, 42 collaborative relationship (Chadwick) empiricism: “bad empiricism” 4; British 11–12, 16, 113 Empiricists 21, 58; vs dogmatism 3, 111 collective unconscious 18, 81, 87, 97; Escher, S. 32 see also archetypes existentialism 88–9 command hallucinations 18–20 existential-phenomenological theory communication difficulties: and thought (Laing) 5, 88–9, 91, 107 disorder 45 Eysenck Personality Inventory 29 co-morbidity 28 comparator model (Frith) 43–5, 67–8 Feinberg, I. 65, 66 complexes: in Jung’s theory 87 Feyerabend, P. K. 3, 111 Composite International Diagnostic Fonagy, P. 20 Interview (CIDI) 29 Fox, George 37–8 conditioning: and association as process Fred (case study) 125–7 of thought 21 free association 68, 78, 87, 104 Index 137

Freud, Sigmund: Bleuler influenced by 21; Hillis, J. 22 dreams 81; ego, superego and id 79, 80; Hoffman, Ralph: cognitive hallucinations 32, 33; melancholia neuropsychological model of voices 5, and internalisation 82, 101–2; 42, 47–50, 67; difficulties with his “Mourning and Melancholia” 80, theory 50–2, 53; homunculus problem 101; “Remembering, Repeating and 48; and Jaspers 58; philosophical Working Through” 78; Schreber case critiques of 55; self-integration issues study 41; superego 79, 81, 101–2; 112; and Stephens and Graham 72 transference 78–9; unconscious 80–1 homosexuality: classification of as illness 33 Frith, Chris: cognitive neuropsychological homunculus problem 48, 65, 66, 72–3 theory 5, 42–7, 50, 51, 53; The Cognitive Hume, David 59 Neuropsychology of Schizophrenia 43; hypnosis 78 comparator model 43–5, 67–8; and Currie 70; homunculus problem ICD (International Classification of 48, 65, 66; and Jaspers 56, 58; loss of Diseases) 27, 59 metacognition leading to volition 97; id: in analytic theory 80 and Lysaker 21; metarepresentation 21, imagination: and delusions 69–71 45–7, 65; philosophical critiques of 55; infinite regress 48, 51, 54, 65, 66, 68, 73 self-integration issues 112; and Stephens information-processing models: and and Graham 72; thought insertion 43–5, CBT 14–15, 22; and homunculus/ 51, 65–9; voice hearing 43–4 mereological fallacy 72–3; and imagination 71; vs models used Galileo 111 in therapy 3; neuropsychological Gallup: paranormal phenomena poll (2005) information-processing models 4–5, 31 43, 50, 53; and psychodynamic approach general population: delusions in 29–32, 33; 93; sub-personal processes 46 hallucinations in 17, 28–30, 32–3 inner objects/internalisation: in analytic Gerrans, P. 42, 68–9 theory 82, 101 gestalt psychology 16–17, 20, 27, 32, 52, introjection: in analytic theory 79, 80 108, 114 “ghost in the machine” myth 35 James, William: The Varieties of Religious Gipps, R. 62 Experience 36 Goffman, E. 36 James I, King of England 35 Graham, G. 56; When Self-Consciousness Jane (case study) 124–5 Breaks (Stephens and Graham) 49, 71–2 Janet, Pierre 21 Gras, A. 26 Jaspers, Karl: descriptions of psychosis 42; misrepresentation of his views 5; Hacker, P. M. S. 73 phenomenological account of psychosis hallucinations: and borderline personality 55, 56–65; and Sue case study 118; disorder vs brief psychotic experiences on Swedenborg’s “schizophrenia” 36, 26–7; and CBT 10; census of (1894) 38; and Tom case study 122 28; command hallucinations 18–20; Jaynes, Julius 32 in general population 17, 28–30, 32–3; Joan of Arc 34 and Maher’s account of delusions 9; Johns, L. C. 30 and metarepresentation 47; pseudo- Johnson, M. 64 hallucinations 27, 63; and splitting Jung, Carl: Bleuler influenced by 21; of self (Laing) 93; and stress 39; visual collective unconscious 18, 81, 87; hallucinations 18, 28, 49–50, 87; complexes 87; ego 87; split personalities see also delusions; mystical experience; and dissociative vs psychotic types 63, voice hearing 102; theory of schizophrenia 87; Heidegger, Martin 57, 59, 60, 89; see also unconscious 87 being-in-the-world Helmholtz, Hermann von 44 Kant, Immanuel 72, 74 Henry (case study) 127–9 Kingdon, D. 11, 39 138 Index

Kingsley, Charles 36 memory: and source monitoring 52; Klein, Melanie: and Cameron 84; fantasies splitting of memories (Bollas) 94; of the infant 78; importance of her work working memory 22 for psychosis 81; and Laing 90, 93, 107; mentalisation therapy 20 origin of psychotic states 77; paranoid- mereological fallacy 72–4 schizoid position 77, 79; projection 79, mescaline 7 99–100; transference 77 Metacognitive and Reﬂective Insight Kraepelin, Emil 7, 41 Therapy (MERIT) 20–3, 114 metacognitive beliefs 20, 53 Laing, R. D.: and Bollas 107; and metaphors 35, 59, 64 Cameron 107; on client as computer 6; metarepresentation (Frith) 21, 45–7, 65 development of psychosis 92–4; The metasexuality (Bollas) 98–100 Divided Self 5, 77, 87–8, 125; existential- Morrison, Anthony 52, 53–4 phenomenological account 5, 88–9, 91, Myers, F. 34–5 107; experimenting with psychotherapy mystical experience: and psychosis 33–9 8; and Fred case study 127; and Henry mythology: vs personal history (Bollas) case study 128; and Klein 90, 93, 107; 95–6 love as crucial therapeutic ingredient 93, 114; ontological security/insecurity narcissism 85, 86, 90, 98 89–91; ontologically insecure person’s negative symptoms 43, 59, 97 fears 91–2, 127; Philadelphia Association Nelson, Hazel 10, 12–16, 20, 96, 106 95; psychological factors leading to neuropsychology see cognitive psychosis 107; psychosis in politics of neuropsychology of “schizophrenia” experience 102; self-integration issues The New Church 36, 38 112; and Sue case study 118; thought Newton, Isaac 35 insertion 94; and Tom case study 123 NICE (National Institute for Health Lakoff, G. 64 and Care Excellence): guidelines for Lewis, S. 10, 20 schizophrenia 8, 20 Locke, John 25 normalisation: chapter overview 4; Losch, M. 29 continuum theory 25–6, 27, 28, 29, loud thoughts 55, 63 39, 41; mystical experience 33–9; love: as crucial therapeutic ingredient normalisation as therapeutic strategy 11, (Laing) 93, 114 25, 39–40; normalisation in practice Lowe, C. F. 9, 10, 11 40–1; psychotic experiences vs LSD 7 borderline personality disorder 26–8; Lysaker, Paul: Metacognitive and psychotic symptoms in general Reﬂective Insight Therapy (MERIT) population 28–33; psychotic symptons 20–3, 114 less normal 39

McGinn, Colin 69–70, 71 objects: communion with/projection into McGlashan, T. 7 (Bollas) 96–8, 99–100 McKellar, P. 29 obsessional thoughts 49, 53–4, 68, 74 Maher, B.: and Bollas 100; and CBT ontological security/insecurity (Laing) 8–9, 10, 14, 20; and delusion of 89–92, 127 thought insertion 68; and Frith 65; Os, J. van 29–30 and Hoffman 48, 51; and Jaspers 57–8, 59, 60; and normalisation 39; and PANSS (Positive and Negative Syndrome Sue case study 117 Scale) 10, 11 Malan, David 105 paranoia: Cameron’s model 77, 79–80, meaning: direct perception of 58, 59–62 84–5, 94, 107; and CBT 11, 19; Frith’s medication: anti-psychotic medication 7, 8; theroy 45; Symington’s theory 85–6; in and normalising approach 39–40; and Waugh’s The Ordeal of Gilbert Pinfold 8; psychotherapy 94–5 see also persecution, sense of melancholia 82, 101–2 paranoid-schizoid position 77, 79 Index 139 paranormal experiences 31, 34–5 and regression 79–80; projective Parnas, J. 59, 125 identification 82; splitting, projection passivity phenomenon 19, 33, 39, 42, 44, and transference 82–3; unconcious 55, 76 and its relation to psychosis 80–2; Perls, Fritz 17 see also psychoanalysis persecution, sense of 56–7, 97, 100, 103; psychosis: terminology issue 4 see also paranoia PSYRATS (Psychotic Symptom Rating personal mythology (Bollas) 95–6 Scales) 10–11 personality disorders: borderline personality PTSD: and psychotic experiences 17 disorder 26–8; and mentalisation therapy 20; and pseudo-hallucinations 63; and Rational Emotive Therapy (RET) 11, 42 psychotic illness vs normal experience Ravenscroft, Ian 69 26; split personality 63, 102; see also self; Read, J. 26 sub-personalities recovery movement 10 Peters, E. 31 Reddy, M. 64 phenomenology: Jaspers’ phenomenological reference: delusions of 35, 45, 61, 85, 88 account of psychosis 55, 56–65; Laing’s regression: in analytic theory 79; in Bollas’s existential-phenomenological theory 5, theory 98, 99–100, 112 88–9, 91, 107 religion see conversion experiences; Philadelphia Association 95 mystical experience philosophical psychology: chapter overview Rhodes, J. 62 5, 55; Frith on thought insertion and role theory 79 Campbell 65–9; Hacker and Bennett on Romme, Marius 32–3 mereological fallacy 72–4; Jaspers’ Ross, C. 28 phenomenology 56–65; McGinn on Ryle, Anthony 79 imagination and delusion 69–71; Ryle, Gilbert 35, 79 Stephens and Graham on thought insertion 71–2; Strawson and Sacks, Oliver 32 identification of persons 74–6 Sartre, Jean-Paul 69 political dissent: classification of as illness 33 Sass, L. 59, 125 Posey, T. 29 SCAN (Schedules for Clinical Assessment possession 34–5 in Neuropsychiatry): criteria for Powell, E. G. 9 delusions 30–1 Premack, D. 46 schema therapy 16–17, 78 projection/projective identification: in schizophrenia: terminology issue 4 analytic theory 79–80, 82, 83; and Schneider, Kurt 35 paranoia 84–5; projecting into the other Schreber, Daniel 41 person (Klein) 79, 99–100; projection Schroeder, K. 26 into objects (Bollas) 96–8, 99–100 scientific methods: dogmatism vs pseudo-hallucinations 27, 63 empiricism 3, 111 psychoanalysis: Bollas 94–108; chapter Searle, J. R. 67 overview 5, 77–8; concepts 78–83; Segal, Hanna 87–8, 103, 105, 123 Jung 87; Laing 88–94; paranoia 84–6; self: divided self and psychoanalysis 80; psychodynamic ideas and psychosis splitting of and psychosis (Laing ) 92–4; 87–8, 108; see also Bollas, Christopher; see also personality disorders; Freud, Sigmund; Jung, Carl; Laing, R. sub-personalities D.; psychodynamic concepts; therapeutic self-alienation 52, 66, 72, 94, 102–3, 111 applications self-deception 14 psychodynamic concepts: early experiences self-esteem 12, 15, 19, 113 of infant and analytic process 78; ego, self-integration 112 superego and id 79, 80; hypnosis, free Shaw, Bernard: Saint Joan 34 association, transference and unconscious Sheldrake, R. 35 78–9; inner objects/internalisation 82; Sherrington, Charles 44 projection, projective identification Shoemaker, S. 67 140 Index

Sidgwick, H. 28 thought insertion: and CBT 19–20; and Slade, P. 112 cognitive neuropsychology 42; Frith and Slotema, C. W. 26 Campbell on 65–9; Frith on 43–5, 51; Society of Friends 37, 38 Hoffman on 51; Jaspers on 56, 58, 62–4; Socrates 34 Laing on 94; and Peters scale 31; and SOCRATES trial 10, 20 philosophical psychology 55; Stephens Soteria project 95 and Graham on 71–2; Strawson on 76 source monitoring 52–4 Tolstoy, Leo 36 Soviet Union: political dissent as illness 33 Tom (case study) 119–24 split personality 63, 102; see also transcendence 96 sub-personalities transference: in analytic theory 78–9, 83; splitting: in analytic theory 82–3; of counter-transference 108, 114; in memories (Bollas) 94; and paranoia Kleinian theory 77; negative transference 84–5; of the self and psychosis (Laing) 123 92–4 Trower, P. 11–12 Steiner, Deborah 82, 101 Turkington, D. 11, 39 Stephens, G. Lynn: When Self-Consciousness Breaks (Stephens and Graham) 49, 71–2 unconscious: in analytic theory 79; in Stoicism 23 Bollas’s theory 99; collective Strauss, J. S. 30 unconscious 18, 81, 87, 97; in Jung’s Strawson, Peter 16, 64, 72, 74, 75–6, 89 theory 87; and relation to psychosis 80–2 stress: and hallucinations 39; and psychotic experiences 17 voice hearing: Arieti’s therapeutic approach Structured Clinical Interview for Diagnosis 88; Bollas’s theory 100–3, 104, 106, 114; (SCID) 29 and CBT 11, 12, 15, 17, 19; Frith’s sub-personalities: in analytic theory 80, 82; theroy 43–4; Hoffman’s theory 42, in Jung’s theory 87; and Sue case study 47–52; interpreting the motivation 117–18; and superego 101–2; and voice of voices 113–14; Morrison, Bentall hearing in Bollas’s theory 101–2 and source monitoring 52–4; and Sue (case study) 115–19 normalisation 40–1; and personality vs Sullivan, Harry Stack 88 psychotic disorders 63; role-playing with superego: in analytic theory 79, 80, 81, voices 19, 114; Romme and Escher’s 101–2 study 32–3; and splitting of self (Laing) Sutherland, Stuart 14 93, 94; Stephens and Graham’s theory Swedenborg, Emmanuel 36, 38 72; and sub-personalities (Jung) 87; and Symington, Neville 85–6, 102 superego 80; Symington’s theory 86; Symonds, J. A. 36–7 see also delusions; hallucinations; thought insertion Tarrier, N. 19 Tavistock Institute 77, 89, 102 Watts, F. N. 9 telepathy 31, 35, 38–9, 62 Waugh, Evelyn: The Ordeal of Gilbert theory of mind 5, 45, 46, 76 Pinfold 8, 100 therapeutic applications: chapter overview Wells, H. G. 75 5; combining approaches 111–12; White, Michael 23–4 counter-transference 114; interpreting Williams, Bernard 71 the motivation of voices 113–14; Winnicott, Donald 89, 90 reconstructing a narrative 112–13; witches 35 understanting psychosis psychologically Wittgenstein, L. 48, 49, 62, 64–5, 69, 74–5 114; see also case studies Woodruff, G. 46 thought broadcast 31, 42, 63, 69; see also word association tests 87 loud thoughts working memory 22 thought disorder 45, 48, 50, 68, 86 thought extraction 63 Young, J. E. 17