Wednesday, 14 May 2008

Reconciling Biological and Psychodynamic Perspectives on Psychosis

Different models of psychotherapy, which present themselves as treatments for 'various difficulties of the human condition', often turn out to best be suited for the treatment of particular kinds of people with very particular kinds of problems. So too, different models of either psychosis in general or of psychotic conditions such as schizophrenia in particular present themselves as 'the theory' for the symptoms one finds in the clinic. This can be very puzzling when we are confronted with two different models which both seem to have value, and when we want to avoid any overly easy explanatory pluralism. Thus the evidence for a genetic predisposition to schizotaxia (a trait itself disposing towards schizophrenia) seems fairly strong, and the various movement disturbances and other 'soft signs' of psychotic conditions seem to rule out any purely psychodynamic explication. And yet at the same time we often meet, in psychotic conditions, with extraordinary defence mechanisms and with delusional and other contents which seem to cry out for psychodynamic understanding. How do we understand their co-occurrence?

In this post I want to propose one simple answer for certain particular difficulties. And it takes its lead from offering a recognition of the fact that particular defences, like particular plants, require certain soils in which they can grow. Many 'primitive' defences would be very hard to mobilise in the well-adjusted. Even defences such as self-deception or denial would often be hard to pull off, since we are so often brought up in front of ourselves that the effort required to sustain the denial would be near impossible. Only in certain conditions can certain defences realistically stand a chance of being employed.

I want to focus on the defences often operative in paranoia, in which bad parts of the self are located in the world (as a defence against feeling bad in oneself), only for the projector to then experience the world as a bad and persecutory place. What kind of soil is required for this defence to grow in? It seems to me extraordinary to suppose that we can just help ourselves to the idea that this defence itself explains the entire psychotic state. This is because the mind boggles when it tries to understand how such a defence could ever be pulled off in the first place.

But consider now the possibility that the neurobiological foundations of what the phenomenologists call our intentional field (the spatio-temporal 'clearing' which constitutes our orienting relation to a world of objects, and which separates out, as its two poles, the self and the object/other) become fragile or vulnerable. Or, to deploy Pierre Janet's schema, the neurobiological tension required to sustain certain levels of consciousness up to the fonction du reel becomes compromised in certain conditions. As a consquence we are left with a soil ripe for the operation of particular defences.

If we consider a weakness in either of these functions, we understand how a proliferation of merely associative thinking and correlative lack of fonction du reel may make possible the frequent use of defences such as self-deception. Character structures with marked splits in their associated associative webs will also play their part here. But what interests me more is the idea that, when the intentional field is weakened, the possibility of a reversal, an inside-out flip, an involution of intentionality, may occur. The ease with which the two poles may be conflated is greatly increased.

Now we only have to imagine someone with this vulnerability encountering the kinds of interpersonal emotional insults that we all encounter (guilt, shame, inability to deal with (to 'think' as Bion would say) one's own murderous feelings, anger, sexual identity confusion, unrequited love, and so on), and it becomes readily apparent how and why they can deploy defences that could not even get off the ground in someone without a psychosis (but with the same conflicts). What better precondition for the operation of projective identification than an intentional field that only takes a little affective shove before it becomes entirely involuted?

What seems important to me about this kind of explanation is that it is in no way an over-easy invocation of, for example, the need for 'bio-psycho-social' models, nor a facile invocation of 'identity theories of mind and brain' at a general level to supposedly perform the reconciliatory work for us, nor an obscure Jungian theory of the supposed toxic efffect that certain ideas can have on the brain, nor any theoretically un-derived divvying out to different sciences the task of explaining diverse symptoms. Nor, I believe, is there here a failure to apply Occam's razor (or at least, there is a 'failure' to apply it indiscrimately, yet such a 'failure' could hardly count against anyone attempting to do justice ot the complexities of the diverse structures of experience met with in for example the schizophrenias.) Instead we have an honest acknowledgement of the undeniable fact that the conditions for the possibility (the 'soil') of certain defences that strike us in the face in the psychoses may well be precisely provided by the neurobiological disturbances encountered there. The neurobiology does not account for the content, only for its possibility. The content does not account for the vulnerability, only for its exploitation. This, I believe, is just one example of how what Charles Taylor called 'peaceful coexistence in psychology' may one day become possible.