Division Review #23 - Spring 2021

DIVISION A QUARTERLY PSYCHOANALYTIC FORUM

NO.23 SPRING 2021

THE WRITING CURE | MALKIN | Lieber

T H E

A N A L Y T I C

F I E L D

PSYCHODYNAMIC TREATMENT FOR PSYCHOSIS | KNAFO and SELZER

R E M I N I S C E N C E DEATH WISHES | KAHR

CHARLES | KARON

PSYCHOSIS AND PSYCHOANALYSIS | BIEN and BROWN

C O M M E N T A R I E S POSTPARTUM PSYCHOSIS | CHO DENNIS MCNULTY

Ars Psychotica

ARCHIVE OF ADJUSTMENTS | HEALEY

P H O T O G R A P H Y Loren DENT

In Civilization and its Discontents, Freud (1930) enumerates a series of “technique[s] in the art of living” (p.81) that individuals employ to mitigate the consequent suffering of the demands made of culture upon the drives. Among these techniques is madness itself, an attempt to delusionally re-construct the world as one wishes in a futile attempt to fend off reality’s misery. Freud’s madman, though, “finds no one to help him in carrying through his delusion” (Freud, 1930, p.81). But while no one is willing to help the madman in his remolding of reality, Freud is quick to note that much of social life is organized around mass delusion to “procure a certainty of happiness.” Despite the phenomenology of psychosis, which often includes isolation through withdrawing from the world, Freud in the above passage points to the inseparability of madness and collectivity, a point he had already alluded to in

his prior Group Psychology, where he refuted the simplistic opposition between individual and social, including for the most extreme of “narcissistic” illnesses (1921, p.69).

Several disciplines in the 20th and 21st centuries have addressed the encounters and chiasms between psychosis and the collective, including psychiatry, social work, sociology, and critical theory (e.g., the work of the Frankfurt School). As is often noted, the history of psychoanalysis and its approach to the treatment of psychosis is a thorny one, despite the encouragement of traditions including Kleinian, Bionian, and Lacanian to listen to madness with analytic ears. At the same time, psychoanalysts were integral to the development of a rich history of institutional and community therapies, such as the Chestnut Lodge and Austen Riggs in the U.S., as well as the work of François Tosquelles and Jean Oury in France and

Franz Fanon in Algeria (Mackie, 2006; Robcis, 2016, 2020). More recent analytically-informed undertakings, among several others, have included the Psychosis Therapy Project in London (Gherovici, Steinkoler, and Bonnigal-Katz, 2018; Bonnigal-Katz, 2019) and the 388/GIFRIC in Quebec (Apollon, Bergeron and Cantin, 2002).

In the United States over the past 20 years, the fields of psychiatry and public health have developed various psychosocial and rehabilitative models for recovery, often referred to as “coordinated specialty care.”

These approaches, typically funded by significant state and federal grants, aim to provide multiple treatments for young people at high risk or experiencing their first episode of frank psychosis. Patients receiving care from these programs are typically offered psychotherapy, medication management, educational or professional coaching, and in some cases,

Official publication of Division of Psychoanalysis (39) of the American Psychological Association

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EDITOR

Loren Dent SENIOR EDITORS

Steven David Axelrod, J. Todd Dean, William Fried, William MacGillivray, Marian Margulies, Bettina Mathes, Manya Steinkoler CONTRIBUTING EDITORS

Gemma Marangoni Ainslie, Ricardo Ainslie, Christina Biedermann, Chris Bonovitz, Steven Botticelli, Ghislaine Boulanger, Patricia Gherovici, Peter Goldberg, Adrienne Harris, Elliott Jurist, Jane Kupersmidt, Paola Mieli, Donald Moss, Ronald Naso, Donna Orange, Robert Prince, Allan Schore, Robert Stolorow, Nina Thomas, Usha Tummala, Jamieson Webster, Lynne Zeavin

CONTENTS THE ANALYTIC FIELD

BOOK REVIEW EDITOR

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Victoria Malkin

The Writing Cure

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Danielle Knafo and

Michael Selzer

Psychosis: A Handbook for the Psychodynamic Treatment of Serious Mental Illness / A preview

Anna Fishzon

Marilyn Charles

David Lichtenstein PHOTOGRAPHY BY

Mac Adams, Barbara Bloom, Jennifer Bolande, Elinor Carucci, Valerie Connor, Gina De Naia, Hanna El Alfi, Allen Frame, Rachel Jackson, Mona Kowalska, Mikael Levin, Susan Macwilliam, Tim Maul, Laurel Nakadate, Tiana Peterson, J. John Priola, James Siena, Michael Smith, Steel Stillman, Beat Streuli, Brooke Tomiello, Gus Van Sant, James Welling

REMINISCENCE 11

FOUNDING EDITOR

Remembering Bert Karon

IMAGES EDITOR

Tim Maul

COMMENTARIES AND TESTIMONIES

Hannah Alderfer, HHA design, NYC

Death Wishes Towards Babies: The Unconscious Roots of Schizophrenia

In Conversation: A Dialogue on Psychosis, Psychoanalysis, and the Peer/Survivor Movement—Claire Bien and Marie Brown

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Brett Kahr

DESIGN BY

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Catherine Cho

Postpartum Psychosis

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Michael N. Healey

An Archive of Adjustments: Reflections of the Remnants of Discarded Diagnosis

DIVISION | REVIEW a quarterly psychoanalytic forum published by the Division of Psychoanalysis (39) of the American Psychological Association, 2615 Amesbury Road, Winston-Salem, NC 27103.

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DIVISION | REVIEW can be read online at divisionreview.com

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Editor’s Note

(from page 1)

the support of a peer (Dixon et al., 2015).

These programs undoubtedly depart from “treatment as usual” (medication, prolonged hospitalizations, and chronicity) and are oriented toward relinking patients to a social world. Nevertheless, coordinated specialty care, along with the expanding definitions of “at-risk” and “early intervention,” have been subject to critical concern for their implicit biopolitical motivations (Liebert, 2014; Berkhout, 2018). Alongside, and sometimes intertwining with, the emergence of such public psychiatry projects for psychosis has been the growing presence and influence of peer and survivor movements. Peers — in this case, individuals who have experienced psychosis or extreme states — have increasingly organized in various forms of collectivity, from the Icarus Project (DuBrul, 2014) and the Institute for the Development of Human Arts in New York City to more formal peer training programs integrated into more extensive psychiatric and psychosocial programs.

Psychoanalysts and psychodynamic clinicians continue developing and inventing ways of working with psychosis, with several

contributions to the field in recent years (e.g., Vanheule, 2017; Rosenfeld, 2018; Downing and Mills, 2018; Garrett, 2019). As such work continues, clinicians will face ethical and political questions, which are necessarily collective. With the shifts in psychiatric, psychosocial, and rehabilitative treatments away from the dusty history of the asylum, how will analysts and analytic therapists listen to and work with extreme states and psychosis, while holding in mind the politics of what Oury described as “that which can turn the collective whole toward a concentrationist or segregationist structure” (Cited in Robcis, 2016)? The present issue of DIVISION/Review aims to sustain the discourse between psychoanalysis and psychosis with such urgent questions in the air. z REFERENCES Apollon, W., Bergeron, D., & Cantin, L. (2002). After Lacan: Clinical practice and the subject of the unconscious.

SUNY Press.

Bonnigal-Katz, D. (2019). Psychosis Therapy Project: A psychoanalytic project in the community. British Journal of Psychotherapy, 35(4), 586-589.

Berkhout, S. G. (2018). Paradigm shift? Purity, progress and the origins of first-episode psychosis. Medical Humanities, 44(3), 172-180.

Dixon, L. B., Goldman, H. H., Bennett, M. E., Wang, Y., McNamara, K. A., Mendon, S. J., ... & Essock, S. M.

(2015). Implementing coordinated specialty care for early psychosis: the RAISE Connection Program. Psychiatric Services, 66(7), 691-698.

Downing, D.L., & Mills, J. (2017). Outpatient Treatment of Psychosis, psychodynamic approaches to evidencebased practice. London, England: Karnac Books.

DuBrul, S. A. (2014). The Icarus Project: A counter narrative for psychic diversity. Journal of Medical Humanities, 35(3), 257-271.

Freud, S. (1921). Group Psychology and the Analysis of the Ego. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XVIII (1920-1922): Beyond the Pleasure Principle, Group Psychology and Other Works, 65-144 __(1930). Civilization and its Discontents. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XXI (1927-1931): The Future of an Illusion, Civilization and its Discontents, and Other Works, 57-146 Garrett, M. (2019). Psychotherapy for psychosis: Integrating cognitive-Behavioral and psychodynamic treatment. Guilford Publications.

Gherovici, P., Steinkoler, M. and Bonnigal-Katz, D. (2018).

Psychosis Therapy Project: An Innovative Psychoanalytic Treatment Program. DIVISION/Rev., 18:20-22 Liebert, R. J. (2014). Psy policing: The borderlands of psychiatry and security. Power and the Psychiatric Apparatus: Repression, Transformation and Assistance, 217-232.

Mackie, B. (2016). Treating People with Psychosis in institutions: A Psychoanalytic Perspective. London: Karnac.

Robcis, C. (2016). François Tosquelles and the psychiatric revolution in postwar France. Constellations, 23(2), 212-222. __(2020). Frantz Fanon, institutional psychotherapy, and the decolonization of psychiatry. Journal of the History of Ideas, 81(2), 303-325.

Rosenfeld, H. A. (2018). Psychotic states: A psychoanalytic approach. Routledge.

Vanheule, S. (2017). Conceptualizing and treating psychosis: a Lacanian perspective. British Journal of Psychotherapy, 33(3), 388-398.

Photography of Dennis McNulty by Tim Maul The following images were taken on my phone while walking in Walkinstown in Summer 2020. All the spaces documented here are tucked away behind standard suburban semi-detached and terraced houses. I presume these alleyways were intended to provide rear access to the houses lining the roads to the front. I hope to find a definitive answer to this question in the course of researching the history of the area and its planning. Over time, most residents have built some kind of structure at the end of their garden, a shed, a workshop or a gym. These buildings double as a secure boundary. As each was built by the individual owner at various times, to different plans and from different materials, they form an incredibly rich patchwork of vernacular architecture. As a consequence of this, the sides of the alleyways are uneven and textured, riddled with narrow gaps and strange angular spaces where non-orthogonal walls meet. Nature pokes through from all directions, pushing its way through the evidence of many generations of subcultural activity. I find myself reading these spaces in the same way a geologist reads the layers in sedimented rock.Their physical form exhibits the effects of slow change over a long period of time, change that was motivated by economic constraints, the ebb and flow of socio-cultural norms, perceived threats to survival and a whole mess of complex forces, some consciously registered and others bubbling away below the surface.

Dennis McNulty 11/20 www.dennismcnulty.com The photograph as document cannot be peeled away from the biography of its maker. Walkinstown is the aptly named suburb of Dublin that I may have driven through during a impulsive (map-free) road trip I took between a B&B in Ranalagh and Thurles in Tipperary County (family). I was promptly lost, circling my way around featureless streets until finally giving into signage that directed me out. Mazes featured in cinema are conducive to panic if we lose orientation and collapse exhausted in their center to freeze to death. But with GPS tracking on every iPhone can anyone still get lost? Dennis McNulty’s practice addresses ‘drift’ and ‘flow’ and these 12 concise images of this 3

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district signify the local where improvised form describes function.

Most suburbs elude the photogenic and here the roads and purposeful sheds comprise the bottom half of each image under a low grey sky with a glimpse of higher elevations beyond. Anything brightly colored offers relief and holds our eye, doors, dog bowl, a bright yellow gating system or the side of a van.

The vastly influential artists Hilla and Bernd Becher led a nomadic Volkswagen van existence driving through bleak postwar industrial landscapes in their adopted roles as archeologists/documentarians. A map of their travels would drop an dense intricate web across Europe and the US. If their project sounds romantic, their photographs famously, were not. McNulty’s engagement here is intuitive and brisk, pictures ‘captured’ on an iPhone which has radically democratized the medium of photography and in doing so may have made teaching any related skill redundant. McNulty’s ‘geological’ forensic examination suggests the visionary ‘land artist’ Robert Smithson, who explored the polluted wastelands of New Jersey like an visiting alien with a ‘point and shoot’ camera. His essay ‘A Tour of the Monuments of Passaic, New Jersey ‘ (1967) dropped my jaw and changed my life.

Smithson, (and maybe McNulty) regarded maps as fictions not to be trusted. What would he of made of the internet when a quick Google search of ‘Walkinsown’ brings up stately Drimnagh Castle?, an island of the picaresque embedded in the sprawl around the Georgian Irish capital. Outside my train window traveling into Manhattan backyards depending on zoning laws are subdivided into private junkyards with satellite dishes, dilapidated above ground pools and warrens of rusting overgrown vehicles suspended in entropic devolution.

Alternatively, McNulty’s ‘Walkinstown’ series is a compact jigsaw puzzle of interlocking personal domains navigated best by someone with intimate knowledge of their usage. Except for a lone dog walker they are unpopulated like real estate or crime scene photography, which leads me to darkly conclude that every unpopulated image in whatever context may be a ‘crime scene’. z Tim Maul

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The Writing Cure

by Victoria MALKIN

Toward the end of her book, The Writing Cure, Emma Lieber asks, “where does analysis happen?” (p.126), answering that it happens primarily in the consulting The Writing Cure

by Emma Lieber London, England: Bloomsbury Academic, 2020 160 pp., $100.00 room. This question is the aim of Lieber’s book, and in weaving together strands of experience, writing, novels, dreams and her analysis, she finds an answer: analysis can happen anywhere that we encounter ourselves and our desires through speech and language. But mostly Lieber searches, “. . . in texts, I have always worked with texts, that is to tell me something about myself: my forms of protection, my desire. This is then, iteratively, the only way of coming to know anything about anyone else” (p.129).

With this emphasis, Lieber points to the role of writing in psychoanalysis. And in this case a writing that she hopes will bring her to the end of her treatment. This book is her testimony to her analysis, it is to be her writing, her discovery, and contain within its pages her cure. Writing obviously was intrinsic to Freud’s discovery (or creation) of psychoanalysis, particularly as he moved through various interlocutors, perhaps most famously beginning with Wilhelm Fliess, who we have come to apprehend through the collection of Freud’s desiring and agonizing correspondence, a correspondence made all the more poignant by the destruction of Fliess’s letters.

Fliess’s presence is marked by absence, a gaping hole that makes Freud’s desire ever more present to us as he waits, responds, cajoles, and confesses. A transference that launched a thousand ships. The object a, as a Lacanian would say, that moved Freud to write his cure and ours. Freud’s interlocutors, these intense libidinized friendships that Freud could make and break, each one being where “analysis happened,” left us a treasure trove of ideas and developments, unwritten passions and circulating desires that enabled Freud to bequeath to us his official version. Meanwhile, an unofficial version lay buried in his correspondence and gave us testimony to just how complex are the questions of where and how analysis and its theory emerge. Moreover, as Lieber herself shows in Freud’s use of the metaphors of birth and menstruation when proclaiming his psychoanalytic discoveries to Fliess (p.15), his theory emerges with an underlying sense of the feminine propelling it: an unnamed libidinal drive that Freud sublimates into his hysterical production.

Freud left his autobiography for psychoanalysis; it is personal in the sense that what is revealed is the logic of his desire, with as much or as little of an autobiography as needed for its revelation. We are bequeathed the paradox that psychoanalysis and its transmission have been the products of an official and unofficial version, its history and theory often hiding treatment impasses and gaps that did indeed require the writing cure. From Joan Riviere’s masquerade to Heinz Kohut’s Mr. Z, psychoanalysis and its writing always have been a writing about what was and was not there, what happened and what did not. The history of psychoanalysis is a history of multiple desires. Its theory is intertwined with desire and its absence, with deadlocks and countertransferences disguised as something else, hiding underneath our theoretical great debates and speaking in tongues; a testimony to what was missing, a search for a singular solution to a singular treatment that could then be converted into a universal claim while the writer comes to terms with what did not happen, even when analysis happens.

Lieber, a scholar of Russian literature and now a psychoanalyst of Lacanian orientation, explores what it means to write about an analysis, but with the knowledge that writing is condemned to circle around a search for what was missing, for the lost object, which will only ever be confronted through its double: a representation or copy of something that could never in fact be known (at least in the way that we generally come to know and name through the Symbolic). We are, it seems, always ships passing in the night, a brief encounter whose traces and clues are scattered through dreams, narratives, and speech.

Lieber’s project is to write her analysis, and thus her self, in such a way that will give credence to the idea of the unconscious, “this agency [that] is the property of the person living out its effects; property in the sense that it is claimed as it is articulated, located at the moment that it is addressed, but never really there, as presence” (p.7).

Ironically, of course, to link the unconscious to property is to present us with the question of just who this unconscious belongs to; to testify to how difficult it is to own one’s unconscious when so many others can move in. Beginning with her name, Lieber explores her desire to escape into fiction and its protagonists, from Austin to Dostoyevsky, among others. Lieber here tells us that her solution to living was placing herself within a cast of characters, as if in a novel, a solution that her analysis dissolved.

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In this economical, beautifully written volume, Lieber aspires to write her way to the end of her treatment; not because writing is an endpoint to her analysis, nor because we must end our treatment literally as writers, but because for her, to end treatment is to take up a place in speech.

Her aspiration is to arrive at the place which, for her, following Lacan, means arriving at the position of the analyst. A passage that confirms having taken up speech and desire that then permits entry into a shared commitment with other analysts. This arrival, in the Lacanian tradition, can only ever be self-authorized, even though it is subsequently recognized by others through the procedure of the Pass, a testimony to one’s analytic formation in the form of a transmission through others that leads to a communal legitimation.

Lieber’s book therefore is her own singular version of a pass, where now we, the readers, are both witnesses and addressees, brought into her desire to be an analyst.

Aware she is circumventing the rituals of communal transmission, she nevertheless knows that self-authorization alone is not enough. The process of becoming an analyst, she states, will always involve an address to an other, even though, following the work of Shoshana Felman, a testimony is ultimately an address to oneself, in spite of the context in which the testimony is produced (p.6). Lieber’s book, then, stakes out a position that rejects the formality of the pass, while searching for a way to craft an address beyond a testimony of one.

She seeks with an openness that follows her throughout the book as she charts the multiple positions of her interlocutors and canonical psychoanalytic texts, while trying to locate her own. She evades the solipsism that can threaten to infuse a selfauthorization, while remaining sensitive to the dangers of regulatory practices that have reared their head multiple times in the history of psychoanalysis. For Lieber this book is her testimony, but one she knows full well required others for its telling (p.7).

But there can be no desire for the position of the analyst without the emergence of the patient. The book therefore embodies Lieber’s desire to represent this double move, to write her analysis and to end it.

She seeks, after all, a writing cure. But here, Lieber has to reckon with the very truth that psychoanalysis brought into view: our narratives are inherently unstable, and our narrators untrustworthy. With this death of the narrator, she challenges us to explore what it might mean to write an analysis. What is the testimony that needs to happen? Is it a

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writing of the logic of our desire, or a narrative of discovery? Are we to write what happened? Of our fantasy, or a progression?

If final case and its failures show it is hard enough to tell the tale of an analysis, then writing one’s own analysis is even more difficult; no one can even agree what analytic process is. How can we capture an analysis and represent something that might be beyond representation, more frequently appearing within the performative or dramatic (The Sopranos, In Treatment) than as a representation of the real? The unconscious itself is outside of representation (in spite of all those odd drawings, graphs, topological sketches that remain). What remains at the end of analysis, and what Lieber tries to grapple with throughout this book, are its traces and aftermath, its structural logic and its desire.

Can we in fact be witness to our analysis when it was addressed to the Other?

To write a treatment, given the usual tenor of analytic writing, seems more than likely destined to be either boring or, as Freud might say, interminable. To write of one’s analysis, along with a search for a path towards its ending, is akin to letting go of the object, mourning what came to pass and what did not happen. Is the writing then a holding on or a letting go? Does it mean that to write to the end of our analysis is to search for what was outside of speech; to capture it as it moves away? For to write and repeat is to already shift meaning even when the end is in sight.

Lieber is acutely aware of this problem.

She knows that whatever comes first could have been later: unconscious desire is not a linear process as it arrives through speech.

Nor is knowledge of it cumulative. Linear revelations can be meaningless in the temporality of psychoanalysis, when one section may just as easily refer to a before or after in the logic of desire, and when the attempt to impose narrative onto an event already erases its contingency. In writing Lieber’s testimony, the book offers its own après-coup when Lieber attempts within its structure to provide those signposts and clues whose shape can shift after she reveals her secret when ending the book. Lieber’s placement early in the volume of a discussion of an essay by Donald Antrim, who goes to buy a bed after his mother has died, a bed that is also a coffin, a mourning and a hopedfor new beginning, is the entry for her to tell of her own bed buying as a newlywed along with her entry into an analysis (p.18).

Lieber here, with wry humor that follows her through the book, hints at the bed she made to lie in. This is already the writing of an ending that asks to be revealed.

In searching for her writing cure, Lieber follows the master. Freud’s opus

emerged from within a struggle with his master narrative, written with the phallic certainty of the official version, favoring Oedipus over castration, separation over oceanic feeling, hiding the mother in favor of the father, but consistently challenging certainty through a style that introduced doubt and hedged bets, referring to poetry and art and the navel of unknowability in the dream. In this volcanic bubbling that undercut its own narrative, psychoanalysis perhaps has from the start demonstrated its own dilemma: to write is to wrestle with castration—to face the problem of knowing, representation, and the wish for certainty—the wish to be whole against the trauma of our loss.

For Lieber, her task is to escape the master narrative; the narrative arc that is the trickster masquerading as truth when we can never escape the metaphors, metonyms, and the unconscious structure of desire that shadows it, pointing us in other directions.

To this end, she works to experiment with form as much as content. What does it mean to write as a woman? An academic?

A mother? An analyst, or a patient? How to write in this cacophony of voices, each one with its own demand? Lieber proposes in her first chapter, “On Coming to Write, or, Tell Me About Your Mother,” that such a testimony needs to circumvent a narrative of the primal father, of certainty and truth, and locate the writing in the realm of the maternal, a hard task when the maternal or female voice is one that often demands a coming into being as a separation from the maternal position itself (p.27). How not to confuse analyst and patient when writing of becoming the analyst? In her experimentation, Lieber is searching for that answer, bristling against the possibility of fixed narratives, interrupting herself mid-sentence during academic arguments to insert a dream, a contradiction, or a personal memory, or counteracting an erudite analysis of a text with an unformed thought or a repetition, a confession of lack of knowledge and uncertainty.

Lieber, in essence, through her writing, attempts to represent and work through her own analytic journey, to find her own unconscious desire, its logic or structure alongside the documentation of its traces.

She writes from multiple spaces, personal, academic, maternal, theoretical, fragmented, or phallic, and puts us in the position of sometimes understanding and at other times feeling lost: “stories are not what are at stake in analysis—not because the way we tell them is wrong, not because we don’t have to do the work of telling them . . . but because there narratives are insufficient as testimonies to desire and the speech that is both its cause and effect” (p.19).

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In her testimony, Lieber may even subject the reader to the position of the analyst as she seduces us with meaning and then snatches it back; introduces us to the new but leaves us floundering in the unknown. In this guise, the book generates beyond the sum of its parts, adding up to a sense of discovery, as much about the writer as the ideas she is working with.

In choosing this form, Lieber allies herself with contemporary writers of autotheory, a form now tied up with the feminine (and women, we know, are often tied up), whose intent attempts to negate the binary of the particular and the universal, and/or theory and biography. Assuming her place in a line of auto-theorists, Lieber reinforces the importance of the feminine, where the everyday, the maternal, and the realm of birth and surprise gives rise to a feminine resistance, a resistance to phallic certainty.

Contemporary autotheory takes the endeavor to write about the self in a form that exceeds self-narrative. It is an attempt at a transmission of something that lies beyond the specificity of one’s own journey. It seeks to depart from navel gazing (which, as Freud would have it, always ends up at the unknown) toward a transcendence of the particular, arriving at a theory of self or a performance of desire. Autotheory is a theory for the other within an analysis of one. A song of oneself that speaks beyond oneself, but from the postmodern perch where narrator, subject, and author are made visible in the same text, and in doing so confounds the masculine position of knowledge, where life and theory remain sequestered in their separate realms.

With her desire to find in the telling of herself the emergence of the position of the analyst, Lieber aligns with Freud, auto-theorist par excellence, who ultimately arrived at the birth of psychoanalysis via Fliess with a writing that pulsated with his own hysterical desire.

Similar then to a successful analysis that confronts us with both the excess of meaning and its lack, the book delves into the paradox of presence and absence, meaning and nonsense. Throughout, Lieber returns to the novels that she loves, and in particular to the Russian novels that we can see were the paving stones that pointed her towards her own desire. While appealing to literature, theory, and personal history, she threads this needle through the use of personal signifiers that presented themselves to her in her treatment—signifiers that she claims as particular to her, which then interweave with three organizing signifiers that loosely generate the structure of her book: the double, first love, and the gift.

These signifiers, she argues, are meaningful also in the wider cultural realm. They also loosely encompass in her mind the different registers and/or developmental ideas in

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Lacanian and Freudian theory, respectively: from real, imaginary to symbolic, or preOedipal to Oedipal. Within this structure, she is propelled to explore her texts, from the books of her formation in Russian literature and her love of novels, to canonical texts in psychoanalysis in her training, to formative moments in her early and adult life and the dreams and transference of her analysis.

And all of this is then quilted together through her more personal signifiers, which emerge from names, toys, and dreams in her analysis.

Lieber asks the reader to stick with her, to tolerate her disruptions and trust her writing, to accompany her through an exegesis of psychoanalytic texts, her moves backward and forward within her own history, her marriage and motherhoods, and an identification and impossible desire for her analyst (with whom she dreams she has a baby that we now know comes into being as a book). By the end, in the final section (“The Gift”), Lieber pays homage to the words of others before her, texts and characters from elsewhere. Here is her, and our, problem of becoming: the question of how to take in these texts and make them one’s own. Lieber’s writing takes on this problem through both form and content.

And it opens up the question of how to take up speech. How, Lieber asks, can we be free from the plagiarism or pillaging of the other?—a struggle Lieber illustrates in her recollection of how even in graduate school, she questioned the command that all quotes and sources must be primary, never ransacked from a secondary source or another reader. Why, she asks, is this the case? What is the problem with quotes taken from another? In this memory, we can locate her dilemma: how to exceed the copy, and how to find a singularity in one’s own usage.

Lieber illustrates her own struggle while searching for her own solution, a solution not only to how to write and represent her analysis, or to create a text that pays it homage, but to the question of self-writing as a form of copying; to escape plagiarism, one requires a separation that can be mourned. If Lieber challenged herself to write her way to the end of her treatment, her writing led her elsewhere, as all good writing should. To emerge as an analyst, one must bear the struggles of the patient, perhaps the most epic struggle being how and why to initiate an ending of the libidinal investment that binds us together. For the writer, Lieber tells us, has full control over resolution, but the subject in the world does not. If this book vaults her towards her pass, and into a community of analysts, Lieber also continues with her search for an ending, aware that one can never trade writing for the real. z 6

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Psychosis: A Handbook for the Psychodynamic Treatment of Serious Mental Illness

by Danielle KNAFO and Michael SELZER

How does a new therapist approach a client who is in the midst of a psychotic episode? How does a therapist reach a client who is deemed unreachable? How can therapists understand and make use of what they are feeling when interacting with someone who is attending to auditory hallucinations or who is expressing delusional thinking? How do persons who experience psychotic states and their families understand what they are going through and know how best to move forward?

Our book will address these questions and more. Psychodynamic theory is the most

comprehensive theory that exists, as it takes into account the patient’s developmental influences, conscious and unconscious meaning making, and adaptive efforts at survival.

Psychodynamic therapy is the only approach that makes use of the critical importance of relationships—those that may have contributed to the problems as well as those that can help heal them. Rather than move quickly to eliminate symptoms, as medications and CBT techniques aim to do, we take our time to understand how a person arrived at where they are, which often means witnessing and narrating past traumas. We understand the

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significance of providing safety and collaboratively making meaning of each person’s singular human experience. A key ingredient of the treatment is the therapeutic relationship itself.

Mental health professionals, including psychiatrists, psychologists, social workers, and mental health counselors, are often discouraged with the current standard of treatment for those with serious mental illness. This book will present a perspective on psychosis in clear, accessible, jargon-free language. We intend to show the strong link between trauma (e.g., sexual abuse, physical abuse, emotional/psychological abuse, neglect, parental

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death, and bullying) and psychotic states. We also aim to elaborate on the enduring concepts necessary for the successful treatment of psychosis: focusing on the nonpsychotic as well as psychotic aspects of the personality; viewing the patient as a whole person rather than a collection of symptoms; establishing safety; prioritizing subjective experience and affect; uncovering traumas; meaning making; working with the transference and countertransference; focusing on the patient as a true collaborator in their own treatment; and creating a treatment alliance that provides the glue for a difficult and challenging journey.

In the current era of managed care and psychopharmacology, the psychotherapeutic treatment of psychosis has become rare and often is judged to be inappropriate. For example, Michels (2003) baldly states that

“schizophrenia is a relative contra-indication to psychoanalytic treatment” (p.11).

Opposing this view is Bollas (2013), who argues that psychoanalysis is the treatment of choice for psychosis. Bollas says, “When the person is at their most vulnerable—and especially in breakdown—they are usually particularly amenable to help, and to the development of insight into the self ” (p.7). Such diametrically opposing viewpoints are not uncommon when it comes to the treatment of psychosis, the most well researched, yet least understood, diagnostic category.

Many popular trends have attempted to drive psychodynamic therapy away from the treatment of psychotic individuals (Ophir, 2015). Unlike French and South American Lacanian psychoanalysts and British neo-Kleinian analysts, many American psychotherapists as well as psychoanalysts have disassociated themselves from work with psychosis. The consequence of this distancing is that when psychosis abruptly enters the treatment room—and it often does—clinicians are ill prepared to work with it and all too frequently shift their focus to managing symptoms (usually with medication) rather than exploring them, or clinicians may rid themselves of such patients through referral or hospitalization.

Despite the sizeable body of research that attempts to demonstrate that persons with schizophrenia have specific brain lesions, most schizophrenic patients have normal brains.1 Sommer et al. (2013) found that 74.4% of patients versus 73.4% of controls had normal brains. Such findings do not support a theory for an organic basis of psychosis.

Meanwhile, the “chemical imbalance theory” has resulted in one in five Americans taking daily psychotropic medications (Medco Health Solutions, 2011), with some calling the increased use of these drugs a “failed revolution” (Horgan, 2020; Whitaker & Cosgrove, 2015). Advances in psychopharmacological treatments for schizophrenia have not created a significant improvement in treatment; in fact, there has been a five-fold increase in those diagnosed with psychosis (Leader, 2011). Consequently, there exists profound dissatisfaction in both doctors and patients with the current standard of care (Aviv, 2019; Carlat, 2010; Sawyer, 2015).

The “incurability” of schizophrenia has also turned out to be a myth. The Vermont longitudinal study (Harding et al., 1987) followed 269 patients for 32 years and found that the common notion that “once a schizophrenic, always a schizophrenic” simply does not hold true. In fact, between 50% and 75% of patients achieved considerable improvement or recovery (Harding et al., 1987). In a 1. We prefer the word psychotic to schizophrenic because schizophrenic comes with a highly stigmatizing history. However, when referring to literature or research that employs the word schizophrenia, we do too.

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longitudinal study lasting 20 years, Harrow and his colleagues (2007; 2017) found that those who had not taken antipsychotic medication showed fewer psychotic symptoms and better work histories after 15 years than those who had. In addition, over half of patients on antipsychotic meds stop taking their medications (Dolder et al., 2002). We are not against the use of medication for psychosis; however, we believe, along with many others, that medication is overprescribed and prescribed for longer than necessary. Often, a mild antianxiety medication rather than an antipsychotic medication will do the trick. The “miracle drugs” clearly do not work for everyone; in fact, they can have serious side effects, including weight gain, cognitive haze, dulling of emotions, and early mortality (Gaebel & Ücok, 2008; Hamer & Meunch, 2010; Kroeze et al., 2003; Lader, 1999). Finally, dispensing medications all day can quickly make healthcare practitioners of all stripes feel like they are pill pushers rather than healers. Psychiatrist Daniel Carlat wrote Unhinged (2010) about the crisis in psychiatry, a profession that today mostly prescribes medications to treat symptoms rather than causes.

In the more recent history of psychology, cognitive behavioral therapy (CBT) has become a popular treatment for psychosis (Garrett, 2019; Mander & Kingdon, 2015).

CBT’s emphasis on cognition and behavior, as well as its ease of application, understandably makes it appealing to clinicians. CBT practitioners scrutinize the evidentiary chain that leads to the psychotic’s “flawed” thinking or behavior, with the aim of correcting it by presenting the patient with conventional logic. Either logic supports the patient’s conclusions, or it does not. The therapist appeals to logic and expects/leads the psychotic to “come around” and realize their thinking is irrational. Recent criticism of CBT for psychosis has been voiced by those studying the research that lauded its effectiveness. Some flaws in the research and in its reporting show that a portion of the research did not use blind trials, resulting in up to seven times greater bias towards recording the effects of treatment. When this researcher influence is corrected by blind assessment, the marginal effects of CBT vanish. As of 2014, 75% of published studies “document no significant reductions in positive symptoms, negative symptoms or in the key symptom of hallucinations” (Laws, 2014).

Our approach differs from CBT in that it does not offer an either/or approach, which we think tends to pathologize the patient. We believe the CBT position, with its imposition of a rational/logical worldview, implies that the therapist knows what is best for the patient, thereby potentially “crushing” their belief system (Leader, 2011). We reach conclusions collaboratively through a multifactorial

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process. Another disadvantage to the CBT approach in treating psychosis is that the clinician avoids unconscious communication, which can be of great value in understanding the patient and advancing the treatment.2 For instance, we believe that much information is communicated unconsciously through a person’s symptoms, dreams, and relationships.

In sum, we do not accept the premise that rushing to eliminate symptoms or complexity is helpful. Rather than view a person’s derailments negatively, we view them as opportunities—an open door leading to novel explorations. Breakdowns can lead to breakthroughs. We understand psychotic symptoms as efforts at adaptation and a need for avoidance, as well as strivings for solutions and attempts at survival. Recent research demonstrates just how much psychotic symptoms are, in fact, ways of dealing with trauma (Bentall & Fernyhough, 2008; Davoine & Gaudilliere, 2004; Kirshner, 2015; Moscovitz et al., 2019; Read & Ross, 2003; Shevlin et al., 2008). Research is demonstrating that childhood adversity and abuse are significant risk factors for the development of psychosis (Krabbendam et al., 2004; Varese et al., 2012). After 15 years of studying auditory hallucinations, researchers Romme and Escher concluded that 80-90% of people who hear voices “link traumatic experiences to the origin of their voice hearing” (quoted in Hornstein, 2009, p.40).

Our book aims to be both timely and important. The mental health profession has moved away from therapeutic approaches to treating psychosis, and the results have been disastrous. The brouhaha surrounding the publication of DSM-5, the latest iteration of the Diagnostic and Statistical Manual of Mental Disorders, is evidence of the widespread unhappiness with the medical model, with claims that the DSM-5 has pathologized normal behaviors and has added new diagnoses in order to benefit drug companies (Rapley et al., 2011; Frances, 2013; Sedler, 2016). Similarly, many lament practitioners’ turning to the quick fix of pharmacology rather than simply talking to people.

Too many training programs do not even teach residents, fellows, or psychologists and social workers how to work therapeutically with serious mental illness because very few know how to do so. This book aims to close the gap. We not only show how there was a time when psychoanalytic therapy was the sine qua non in the treatment of psychosis, but also demonstrate how psychosis is best alleviated, given the knowledge and treatment modes that are at our disposal today.

There exists a growing recovery movement that seeks alternative ways of approaching psychosis. This movement emphasizes 2. Garrett (2019) is an exception; he integrates CBT and psychodynamic approaches and, as such, includes working with the unconscious.

the need for patients to participate in their own recovery (Glynn et al., 2006). In addition, attempts to create alternatives to medication treatments and hospitalizations are taking place in numerous countries, including Canada, Israel, Sweden, Norway, Finland, and Denmark. Finally, recent international research is demonstrating how psychodynamic treatment with persons diagnosed with psychosis (even treatment-resistant patients) results in significant long-term improvement and dramatic reduction in symptoms and hospitalizations when compared to “treatment as usual” (Amir & Shefler, 2020; Rosenbaum, 2015).

All of the above constitute clear signs that clinicians and patients alike are ready and eager to learn more about a nonjudgmental and collaborative treatment methodology that challenges the assumptions that psychosis is not treatable by therapeutic methods and that psychotic individuals cannot engage in psychoanalytic psychotherapy. We offer an alternative state-of-the-art treatment approach that respects the psychotic person’s subjectivity and experiences and recognizes their own resources and creativity. Our approach trains professionals how to join with their patients to make meaning of their experiences by forming a mutual relationship that helps them emerge from confusion, fear, alienation, and despair. z REFERENCES Amir, I., & Shefler, G. (2020). The “Lechol Nefesh” project: Intensive and long-term psychoanalytic psychotherapy in public mental health centers. Psychoanalytic Inquiry, 40(7) 1-12.

Aviv, R. (2019, Apr. 1). The challenge of going off psychiatric drugs. The New Yorker. https:// www.newyorker.com/magazine/2019/04/08/ the-challenge-of-going-off-psychiatric-drugs Bentall, R., & Fernyhough, C. (2008). Social predictors of psychotic experiences: Specificity and psychological mechanisms. Schizophrenia Bulletin, 34(6), 1012–1020.

Bollas, C. (2013). Catch them before they fall: The psychoanalysis of breakdown. Hove, England and New York, NY: Routledge.

Carlat, D. (2010). Unhinged: The trouble with psychiatry—A doctor’s revelations about a profession in crisis. New York, NY: Free Press.

Davoine, F., & Gaudilliere, J. M. (2004). History beyond trauma. New York, NY: Other Press.

Dolder, C. R., Dunn, L. B., Leckband, S. G., Lacro, J. P., Leckband, S. G., & Jeste, D. V. (2002). Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. Journal of Clinical Psychiatry, 63(10), 892–909. https://doi:10.4088/ jcp.v63n1007 Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma and the medicalization of ordinary life. New York, NY: William Morrow.

Garrett, M. (2019). Psychotherapy for psychosis: Integrating cognitive-behavioral and psychodynamic treatment. New York, NY: Guilford.

Gaebel, W., & Ücok, A. (2008). Side effects of atypical antipsychotics: A brief overview. World Psychiatry, 7(1), 58–62. https://doi:10.1002/j.2051-5545.2008.tb00154.x Glynn, S., Cohen, A., Dixon, L., & Niv, N. (2006). The potential impact of the recovery movement on family interventions for schizophrenia: Opportunities and obstacles.

Schizophrenia Bulletin, 32(3), 451-463.

Hamer, A. M., & Meunch, J. (2010). Adverse effects of antipsychotic medications. American Family Physician, 81(5), 617–622.

Harding, C., Brooks, G., Ashikaga, T., Strauss, J., & Breier, A. (1987). The Vermont longitudinal study of persons with 10

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severe mental illness, I: Methodology, study sample, and overall status 32 years later. American Journal of Psychiatry, 144(6), 718–726.

Harrow, M., Jobe, T., Faull, R., & Yang, J. (2017). A 20-year multi-followup longitudinal study assessing whether antipsychotic medications contribute to work functioning in schizophrenia. Psychiatry Research, 256, 267–274.

Harrow, M., Jobe, T., & Thomas, H. (2007). Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: A 15-year multifollow-up study.

The Journal of Nervous and Mental Disease, 195(5), 406–414.

Horgan, J. (2020, Oct. 17). Has the drug-based approach to mental illness failed? Scientific American. https://www.scientificamerican.com/article/ has-the-drug-based-approach-to-mental-illness-failed/ Hornstein, G. (2009). Agnes’s jacket: A psychologist’s search for the meaning of madness. Emmaus, PA: Rodale.

Kirshner, L. A. (2015). Trauma and psychosis: A review and framework for psychoanalytic understanding. International Forum of Psychoanalysis, 24(4), 216–224. https://doi.org/10.10 80/0803706X.2013.778422 Krabbendam, J., Bak, M., Vollebergh, W., de Graaf, R., & van Os, J. (2004). Childhood abuse as a risk factor for psychotic experience. Acta Psychiatry Scandinavia, 109(1), 38–45.

Kroeze, W., Hufeisen, S., & Popadak, B. (2003). H1histamine receptor affinity predicts short-term weight gain for typical and atypical antipsychotic drugs.

Neuropsychopharmacology, 28, 519–526. https://doi. org/10.1038/sj.npp.1300027 Lader, M. (1999). Some adverse effects of antipsychotics: Prevention and treatment. The Journal of Clinical Psychiatry, 60 Suppl 12, 18–21.

Laws, K. (2014, Apr. 2). Has cognitive behavioral therapy for psychosis been oversold? The Guardian. https:// www.theguardian.com/science/sifting-the-evidence/2014/ apr/02/has-cognitive-behavioural-therapy-for-psychosis-been-oversold Leader, D. (2011). What is madness? London, England: Penguin.

Mander, H., & Kingdon, D. (2015). The evolution of cognitive-behavioral therapy for psychosis. Psychology Research and Behavior Management, 8, 63–69. https://doi.org/10.2147/ PRBM.S52267 Medco Health Solutions (2011). Mind: New report finds Americans increasingly turn to medications to ease their mental woes; women lead the trend. https://www.prnewswire.com/news-releases/americas-state-of-mind-new-reportfinds-americans-increasingly-turn-to-medications-to-easetheir-mental-woes-women-lead-the-trend-133939038.html Michels, R. (2003). The relationship between psychoanalysis and schizophrenia by Richard Lucas—a commentary.

International Journal of Psychoanalysis, 84(1), 9–12.

Moscovitz, A., Dorahy, M., & Schafer, I. (2019). Psychosis, trauma and dissociation: Evolving perspectives on severe psychopathology. Hoboken, NJ: Wiley.

Ophir, O. (2015). Psychosis, psychoanalysis and psychiatry in postwar USA: On the borderland of madness. Hove, England and New York, NY: Routledge.

Rapley, M., Moncrieff, J., & Dillon, J. (2011). Carving nature at its joints? DSM and the medicalization of everyday life.

In Mark Rapley, Joanna Moncrieff, & Jacqui Dillon (Eds.), Demedicalizing misery. London, England: Palgrave MacMillan. https://doi.org/10.1057/9780230342507_1 Read, J., & Ross, C. A. (2003). Psychological trauma and psychosis: Another reason why people diagnosed schizophrenic must be offered psychological therapies. Journal of the American Academy of Psychoanalysis, 31(1), 247–268.

Rosenbaum, B. (2015). Psychodynamic psychotherapy for persons in states of psychosis: Some research perspectives.

British Journal of Psychotherapy, 31(4), 476-491.

Sawyer, A. P. (2015). Smoking cigarettes, eating glass: A psychologist’s memoir. Santa Fe, NM: Santa Fe Writers Project.

Sedler, M. J. (2016). Medicalization in psychiatry: The medical model, descriptive diagnosis, and lost knowledge.

Medicine, Health Care and Philosophy, 19, 247–252. https://doi. org/10.1007/s11019-015-9670-5 Shevlin, M., Houston, J., Dorahy, M., & Adamson, G. (2008). Cumulative traumas and psychosis: An analysis of the national comorbidity survey and the British psychiatric survey.

Schizophrenia Bulletin, 34(1), 193199.

Sommer, I., de Kort, G., Meijering, A. L., Dazzan, P., Hulshoff, P., Kahn, R., & van Haren, N. (2013). How frequent are radiological abnormalities in patients with psychosis? A review of 1379 MRI scans. Schizophrenia Bulletin, 39(4), 815–819.

Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, Reed, J., van Os, J., & Bentall, R. (2012).

Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, 38(4), 661-671.

Whitaker, R. & Cosgrove, L. (2015). Psychiatry under the influence: Institutional corruption, social injury, and prescriptions for reform. London, England: Palgrave McMillan.

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Remembering Bert Karon I first encountered Bert Karon in the fall of 1989, when I entered graduate school at Michigan State University. Bert was an unassuming yet intriguing figure in the department, known for his investment in clinical work and in humanizing the psychotherapy of schizophrenia. At that point, I didn’t know much about psychoanalysis, only that many of the students in the program had become affiliated with the local psychoanalytic group and that many of the psychoanalysts there were highly valued and sought after as clinical supervisors in the program.

Bert taught the thematic apperception test (TAT) section of our initial assessment class, so I was introduced early on to his particular teaching style, which drew upon personal anecdotes from his clinical work and an enthusiasm for deep immersion into whatever material was under investigation. I was easily enticed into Bert’s way of reading the TAT stories, as he invited us to slow down, resonate with, and think through the texts as we encountered them. In contrast to much of academic reading, where we hurry through, looking for the gist, the point, the salient fact to remember and organize our understanding of the material, here, we were invited to work slowly and deliberately from the individual bits of data, to engage with them and see where they led us. This was a different and profoundly personal way of finding meaning that appealed to the part of me that could readily become absorbed in art, nature, literature, or film; the more associative part that could easily seem unwelcome in a clinical psychology program.

But here, this was precisely what was demanded, and I was soon rapt in the absorbing task of reading deeply, word by word, line by line, through the TAT stories, slowing down sufficiently to be able to allow possible meanings, nuances, subtleties, and associations to register. As the class worked together, reading each word and associating to the words and the meanings as they evolved through our efforts, a story unfolded with richness and subtlety, and our ears and minds became attuned to the particular character of the individual whose story was being told. What better introduction to psychoanalysis than to immerse oneself deeply into the narrative and allow each bit of data to resonate, echo, and unfold, to be able to encounter links without forcing them, and also notice how the gaps speak in their own ways? This would be the same process through which Bert would invite me to read Freud when I entered analytic training some years later.

Bert was a larger-than-life personality in the department, known for his informal

style and for the very large, very old, and very comfortable chair in his office that students—or patients—would be invited to lounge in. Bert’s courses, whatever their title, tended to follow a similar trajectory.

Personal reminiscences would invite the student into the essentially psychoanalytic but, most notably, profoundly humanistic universe of Bert Karon. When I took his course on the psychotherapy of psychosis, I was puzzled. He told stories of working with psychotic individuals whose histories «would have driven anyone crazy.” These stories were exciting and compelling, but his psychotherapy tapes showed interviews of troubled young people engaged in cogent conversation with the interviewer. I was disappointed and perplexed. Where were the psychotic people I had been promised?

It took many years and my own experience as an analyst to truly understand why there was only cogency and not craziness in the tapes, that sincere and deep human engagement invites the same, even when people at times have quite extreme symptoms.

This early experience of respectful engagement formed a solid foundation in meeting a person where I found them, empathizing with their distress, and moving towards conversation during times of strain. I recall one young woman I worked with, in particular, who was causing a great deal of furor amongst the nursing staff in the hospital where I worked. Earnest efforts to engage her in conversation when she was found (literally) turning around in circles were met not with reciprocal engagement, but rather with great irritation. As we talked, she could describe the important rituals she needed to perform when under stress and also the importance of not being distracted during the process. Recognizing that a ritual was being performed that needed to come to its own conclusion helped the nursing staff to avoid exacerbating the distress that she was desperately trying to manage.

This young woman’s speech could devolve into series of numbers when she was upset, but then could regain cogency when she was given attuned attention. By the time I met “Leah,” I had sufficient experience to be able to recognize and meet her disturbance. During those early years of training, however, with no clinical experience of my own, I had no frame of reference through which to make sense of the discrepancies in what I was being taught.

Who were these people Bert was interviewing? Were they just anomalies, random people who had been misdiagnosed and had somehow found their way into Bert’s office? Or was something more systematic 11

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at play? My dilemma was furthered by the exigencies of training in an APA-accredited program, where I was expected to learn a diagnostic manual that informed me of the symptoms of various disorders to be reckoned with, managed, and, perhaps, cured.

In contrast, in these early seminars, I was also being invited into a universe of human suffering in which, as Bert was fond of saying, people were driven crazy by their experiences, including, at times, those initiated by well-intentioned practitioners.

I had sufficient experience of being a woman in this culture, and also knowledge of the history of ways in which some individuals, particularly women, had suffered under the treatment of mental health systems that presumed to know better than they “what was good for them,”“ “to be intrigued by Bert’s profoundly humanistic perspective. I was also studying in a program that included a community psychology area of concentration that provided me with social, contextual, and social justice purviews on the problems from which people suffer. Our introductory course in community psychology took a strong stand for ways in which what is otherwise called “disease” or “disorder” can be a function of unaddressed social ills: dis-ease rather than disease. These lenses helped me to find my own seat as a clinician devoted to keeping my eye on the integrity of the individual being served.

Unlike many of the other professors, who preferred to teach graduate classes, Bert was quite devoted to teaching an introductory class in psychology, where he made sure to acquaint the students with the wonders of Freud. In opposition to the prevalent trope in those days, that Freud was dead, passé, Bert instilled an interest in these young people in the process of discovery that psychoanalysis can afford.

Years later, when I began my own practice, I would always smile when a young student would call to interview me as a prospective therapist, to make sure that I would provide them with the type of opportunity Bert had suggested might be possible in their class. I knew that this was someone who had encountered Bert and caught the bug of self-discovery, and I was grateful for his efforts to open the minds of the students he taught to this invaluable resource.

Through Bert and some of the external supervisors in my program, I became acquainted with the Michigan Psychoanalytic Council, where I eventually received my analytic training. Bert was always particularly receptive to my presence, his warm smile greeting me, welcoming me into the

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company of prospective colleagues who otherwise might have seemed alien. His humility engendered inclusiveness, making us students feel valued and valuable, worth engaging with and taking seriously. I remember him introducing me to colleagues by remarking on my particular aptitude in reading the TAT stories, the recognition coming at a time when I sorely needed it. I am certain that he made others feel similarly special and valued.

Training in clinical psychology can be a bruising experience. Our teachers tend to focus on academic rather than clinical efforts, which was certainly true in my department. The hope was that students would become academics, not merely clinicians, and I determinedly tried to be true to that standard. I enjoyed the intellectual efforts and the research, but over time, it was the integrity and humanistic focus I found in Bert and many of the other analytic su-

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pervisors in the program that called to me.

Here were individuals who were devoted to learning in the service of offering something of substance to those they encountered.

This was quite at odds with the academic environment, which often felt competitive and more intent on “confirming hypotheses” than on learning. Countering the laborious challenges of research per se, in which what one learned might be obscured by the method, I was finding that my own personal

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analysis and the supervision I was receiving were affording me depths of insight that augmented my clinical work and also the academic offerings in my program.

In that situation, where great interest and enthusiasm met a great deal of frustration, Bert drew a circle around him of students and colleagues who were attracted by his warmth, acceptance, and deep humanism. His home was inviting and singularly unpretentious. His wife Mary was always

present, both at home and in professional meetings, always at his side, with her easy, gracious, and loving demeanor. The atmosphere was permeated by care. Our seminars in the analytic institute were notable for their warm encouragement to be at home with one another and with the often-difficult texts we were diving into. There was never a right or wrong answer, only an air of enthusiastic investigation. Mary was so much a part of the atmosphere that when he lost her after the accident, Bert, alone, was almost unimaginable. But Bert was not alone. The terrible automobile accident that left him paralyzed and physically dependent did not decrease the independence of his mind and spirit, and his resiliency and positive attitude invited warmth and care from those who encountered him.

After the accident, Bert disappeared for a bit, but soon began to reappear on the scene, first on email and then in person, particularly at Division 39 and International Society for Psychological and Social Approaches to Psychosis meetings. His was always a kind, calm, and loving presence, and he seemed to stand as an emblem for the best kind of care our field can offer, one steeped in a fundamental respect for the human being, the troubles we face, and our need for support from one another.

He was always surrounded by love, people returning some small measure of what he had given indefatigably over the years. After Mary’s death, it was his caregiver who became his companion, accompanying him also to professional meetings. In kind with the extraordinary being who depended on her care, she was remarkably present, attentive, loving, and receptive to Bert’s deep commitment to his work and to those who shared Bert’s love of psychoanalysis and his devotion to providing intensive, humanistic psychotherapy to those most in need.

When Marie Brown and I began the Division 39 Task Force on Psychosis and Dissociation, we wanted to honor Bert, who has been such a beacon for those of us who are devoted to the respectful treatment of those suffering from severe distress. His book, The Psychotherapy of Schizophrenia, as well as his collected writings, stand as important milestones in the effort to recognize the traumatic antecedents of serious emotional suffering and to focus interventions in relation to that trauma and pain, rather than moving towards medicalized models that tend to dehumanize even as they attempt to ease the suffering. In a world that is becoming increasingly mechanistic, we need more than ever to be able to find and live from the basic human qualities at our core that join us to one another. We need to be able to recognize ways in which mechanistic systems and treatment modules op13

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pose precisely what is needed when people are marginalized, alienated, and suffering.

As I continue to study and practice psychoanalytic psychotherapy, I am struck increasingly by the basic principles that stand at the core of our work. Whatever language our theories are couched in, each seems to point towards the primacy of creating structures within which the person might develop beyond the places where they have gotten stuck. In that way, whether I am framing my work in terms of Winnicott’s good-enough holding environment, in which an individual might discover themselves sufficiently to engage their own creative capacities; Bion’s containment that abstains from memory or desire so as to leave room for the person’s own truth instincts to cohere; or Lacan’s insistence on an ethic that recognizes the analyst’s desire sufficiently to leave room for the patient to find their own, I can find, through these disparate lenses, a focus on the person who has brought their suffering to me as both a problem and also as a story that requires respect and unfolding. I hope that you can recognize the link between this idea of symptoms as manifestations of a story of suffering, and the universe that Bert was trying to hold open for his students, his patients, and his colleagues, where respectful engagement with the suffering of another person who has invited us to accompany them on their journey becomes possible.

I will always be grateful to Bert for providing me with the essential key for unlocking the mysteries of clinical practice and empathic resonance with human suffering, a key that, at its core, is about love, the love that both respects and transcends difference to recognize our common humanity, vulnerability, and responsibility to one another. Whatever we call this work, and whichever theories we use to construct a narrative within which the suffering, respectful engagement, and the journey towards easing the distress make sense, it is the core of humanism that I found in Bert that has helped organize my continued efforts to conduct my work with integrity.

The further I traverse my own path, the more I recognize that it is the authenticity of my relational engagement and my respect for those who invite me to share their own journeys that provide the constituents needed in order to humbly pursue this impossible profession. People come to us for cures, but all we can offer is hope and the possibility of healing, together, what was merely painful and alienating alone. At some level, we count on illuminaries from the past to light the way. For me, Bert was one such shining light in the darkness, reminding me that ours is not a discipline that deals with diseases of the body, but rather, more profoundly, dis-eases of the soul. z

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Death Wishes Towards Babies: The Unconscious Roots of Schizophrenia Brett KAHR

I have worked in the mental health profession for over forty years, during which time I have encountered far too many types of extreme psychopathology: forensic patients, such as pedophiles, rapists, and murderers; survivors of sadistic abuse; post-traumatically stressed soldiers who have witnessed the deaths of comrades on the battlefield; self-cutters and those who have attempted suicide; alcohol and drug addicts; victims and perpetrators of severe domestic violence; major depressives; and many others besides, including, most recently, those who have succumbed to life-threatening breathing difficulties or who have become bereaved through the wretched, horrific COVID-19 pandemic.

Although every single one of these aforementioned patients will have experienced deep distress of one form or another, few people will have struggled as intensely and as painfully and as chronically as those who have come to receive a formal diagnosis of schizophrenia.

Those men and women who must combat this vicious variety of psychotic illness will often manifest a veritable tsunami of symptoms, ranging from frightening auditory hallucinations to terrifying persecutory delusions. Tragically, patients with particularly severe forms of schizophrenia will often descend into seemingly irreversible catatonic states, imagining themselves to be already dead and, hence, unwilling or unable either to speak or to move.

I first began to practice psychotherapy as a very young trainee psychologist, working at a rather run-down British psychiatric hospital built in the 1840s and located in a tiny village, some sixty miles outside of London. In spite of the decrepitude and backwardness of this old-fashioned institution, I had the privilege of receiving clinical supervision from a very kindly consultant psychiatrist who had trained, years previously, with some of Anna Freud’s disciples.

Knowing of my interest in the contributions of Sigmund Freud—rather unusual among British psychologists of the 1970s and 1980s—and of my wish to pursue, one day, a psychoanalytical career, this psychiatrist referred my very first patient to me: a forty-something-year-old man called “Steven,” whose diagnosis vacillated between “paranoid schizophrenia” and “catatonic schizophrenia.”

At times, Steven would spend his days running around the locked in-patient wards, screaming at the top of his lungs, and claiming that the British Broadcasting

Copyright © 2020, 2021, by Professor Brett Kahr. Please do not quote without the permission of the author.

Corporation had penetrated his mind and had transmitted all of his sexual thoughts to the entire nation on the nine o’clock evening news. He also believed that a team of soldiers would enter his communal bedroom on a nightly basis and hypnotize him, before stabbing him in the anus with long bayonets, while he lay helpless.

For years, the psychiatric team offered Steven virtually no treatment other than incarceration and the prescription of rather primitive antipsychotic medication. In desperation, the nurses forced him to swallow 900 milligrams of Largactil, the trade name for the drug known as chlorpromazine (manufactured in the United States as Thorazine). The consultant psychiatrist used to joke, “Gosh, we’ve given him enough of a dose to knock out an elephant.”

Often, Steven’s violent, persecutory thoughts became so overbearing that in spite of the antipsychotics, this miserable patient would lapse into a more catatonic state and would pretend to be dead, neither talking, nor moving, nor even daring to open his eyes for weeks and weeks at a time. Never have I ever worked with such a distressed and tormented human being.

In spite of the fact that I had not yet embarked upon my formal psychoanalytical training or, indeed, upon my own personal psychoanalysis at this very early point in my career, I received the blessing of the dynamically informed psychiatrist who ran our ward to offer Steven three sessions of psychotherapy per week.

To my great delight and surprise, Steven agreed to the plan, and he responded extremely well to these regular, reliable conversations in which I simply listened, calmly and quietly, in a curious and, hopefully, non-judgmental manner.

After several months of this fledgling experience of psychodynamic psychotherapy, Steven’s symptoms actually began to dissipate, and after approximately one year, he seemed to have become so normal and so sensible that the psychiatrist began to reduce his medication on a month-by-month basis until this schizophrenic man no longer required 900 milligrams of Largactil.

His hallucinations and his delusions ceased entirely, and in time, he no longer suffered from catatonic episodes. Moreover, Steven stopped retreating to his bed during the daytime, and eventually, he began to spend his days outdoors in the sunshine, participating in the hospital gardening group. After two years of these regular sessions—held on Mondays, Tuesdays, and 14

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Thursdays—the psychiatrist actually transferred Steven from the in-patient ward to an out-patient facility in the community, several miles away from the hospital.

It pleased me greatly that Steven began to recuperate from his many decades of psychiatric illness and confinement. But what on earth caused his schizophrenia in the first place?

Alas, we have no shortage of theories about the etiology of this most extreme form of psychosis. Our ancient ancestors proffered not only cosmological hypotheses, arguing that lunacy might result from the position of the moon [luna], but also demonological explanations, which proposed that severe madness might well stem from a curse by the Devil. Our predecessors also championed humoral theories, proposing that insanity might be caused by an imbalance in bodily fluids (e.g., Galen, 1656, 2013; cf. Graham, 1967; Jackson, 1969; Gilman, 1982; Nutton, 2013). Such seemingly outlandish conceptualizations persisted across the centuries. In medieval times, the thirteenth-century Franciscan friar Bartholomaeus Anglicus argued that madness might even ensue from the bite of a dog (e.g., Walsh, 1929). Indeed, everyone advanced his or her own unfounded theory about the origins of madness, including the iconic Shakespearean character Polonius, who proclaimed, “I haue found / The very cau∫e of Hamlets Lunacie” (Shakespeare, 1623, First Folio, Actus Secundus, Scena Secunda, lines 51-52).

With the decline in religious observance (e.g., Thomas, 1971; cf. Binion, 1986), and with the consequent growth of dissection and anatomical investigations (e.g., Buklijas, 2008), madness became so increasingly medicalized by the nineteenth century that most physicians had come to regard any signs of insanity as proof of neurological degeneration (e.g., Lombroso, 1876; von Krafft-Ebing, 1895; cf. Gilman, 1984; Colaizzi, 1989; Shorter, 1997; Kahr, 2020b), or of excessive masturbation (Maudsley, 1868), or, even as a consequence of high degrees of atmospheric temperature (Andral, 1833). These etiological theories, though now rather antiquated, nevertheless inspired much of the twentieth-century research on the ostensibly genetic, biochemical, neuropathological and, even virological causes of schizophrenia, which my undergraduate and postgraduate teachers of psychopathology promulgated with unrelenting enthusiasm (e.g., Kallmann & Rypins, 1938; Kallmann, 1946;

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Gottesman & Shields, 1972; Crow, 1978, 1994; Andreasen, 1984, 1986).

Needless to say, the embrace of a proto-biopathological theory of etiology provided the very foundation of many medically oriented treatments for dementia praecox (subsequently renamed schizophrenia) across the last 100 years or so, such as insulin coma therapy (Hill, 1938, 1940; Langfeldt, 1939; Fraser & Sargant, 1940; Jones, 1940; Parker, 1940; Sandison & McGregor, 1942; Tennent, 1944; McConnell, 1945); psychosurgery (Moniz, 1936; McGregor & Crumbie, 1941, 1942; Freeman & Watts, 1942, 1944; cf. Valenstein, 1986; Berrios, 1991, 1997); electroconvulsive treatment (Wilcox, 1947; Fink, 1999; cf. Berrios, 1996; Kneeland & Warren, 2002; Shorter & Healy, 2007; Gilman, 2008); and, more influentially, the various types of psychopharmacology, which included manganese chloride (English, 1929), sodium amytal (Bleckwenn, 1931), histamine (Hill, 1938, 1940), and, ultimately, the more familiar antipsychotic medications still in use (e.g., Levitt, 1975; Lewis et al., 2001; Carvajal et al., 2009).

Although I studied this medically oriented literature thoroughly, I struggled to understand how my very first patient, Steven, could have improved so dramatically simply by talking with me on a thrice-weekly basis for a mere fifty minutes at a time. If he really did suffer from genetic, biochemical, neurological, and virological deficiencies, then, surely, simply chatting away to a young trainee psychologist could hardly change the structure of his brain.

Needless to say, I began to develop a tremendous sense of skepticism towards these more traditional explanations of the etiology of schizophrenia; and, thankfully, having already discovered the work of Sigmund Freud while still in my adolescence, I turned to this great genius for guidance and also for comfort.

As we know, amid the desperate search for biologically oriented theories of causation and, moreover, for surgically or pharmacologically oriented methods of treatment, the brave Viennese physician, Professor Sigmund Freud, trained by some of Austria’s leading psychiatrists, abandoned the so-called medical model entirely.

Based on his extensive clinical investigations of patients, with whom he spent hour upon hour of his time, listening carefully to their erotic secrets in a private consulting room, Freud began to foreground a much more proto-psychological model of madness, suggesting that illnesses such as dementia praecox and schizophrenia stem not from brain degeneration, but rather from intrafamilial factors, including profound sexual conflicts.

As early as 1895, in his “Manuskript H” (Freud, 1895/1950), known in English as “Draft H” (Freud, 1895/1966), written for his Berlin colleague, Dr. Wilhelm Fliess, Freud hypothesized that patients suffering from paranoid delusions—once regarded as insane and senseless—could, in fact, be understood, and that these ostensibly mad thoughts about being persecuted by an external object might well represent a projection of a horrendous internal thought or feeling or memory. Freud (1911) ultimately elaborated upon this theory more extensively in his now landmark analysis of the psychotic German jurist, Daniel Paul Schreber; over the decades, he continued to explore the psychodynamics of psychosis, eventually concluding that madness not only makes sense, but also that seemingly insane delusions might, indeed, contain a kernel of truth (e.g., Freud, 1937).

During my student years, I read the biological literature about schizophrenia with bibliophilic obsession in order to engage with my teachers and my colleagues, but it took me quite some time to appreciate that although the authors of these papers and textbooks on the role of dopamine in schizophrenia wrote with tremendous scientific rigor and gravitas, not a single one ever mentioned a patient by name or ever acknowledged that these schizophrenic men and women whose blood they examined so religiously had experienced an infancy or a childhood.

Thankfully, Freud and his followers provided an alternative narrative, arguing that schizophrenia, though a severe form of mental illness, actually makes sense, and, if studied psychotherapeutically over a period of time, can be cured simply by talking and listening and understanding. Through psychoanalytical investigation, each participant—the patient and the practitioner—would come to discover that seemingly mad symptoms, such as visual hallucinations and grandiose delusions, might well have resulted from very specific childhood traumata.

Reading Freud’s writings on psychosis provided me with such a sense of insight and hope that I began to immerse myself in the enormous, but much marginalized and much forgotten, literature on the psychoanalytical treatment of schizophrenia and other forms of psychosis, most of which emerged from the pens of his Viennese colleagues, many of whom ultimately emigrated to the United States of America in the wake of Nazism (e.g., Fromm-Reichmann, 1943, 1947, 1948, 1954, 1955; Niederland, 1959a, 1959b, 1963, 1974, 1984; Katan, 1975). In Great Britain, almost no one spoke about the potential role of psychoanalysis or psychotherapy in the treatment of schizophrenia, apart from a few of the followers of Melanie Klein, whom 15

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most mental health professionals at that time regarded as little more than the leader of a cult (e.g., Rosenfeld, 1947, 1949, 1950, 1952, 1969, 1976, 1987; Segal, 1950, 1956, 1972, 1975, 1994)!

Nonetheless, in spite of the widespread suspicion towards the psychoanalytical treatment of psychotic patients, I embraced the work of these early geniuses, ranging from Dr. Karl Abraham (1907, 1908) to Dr. Gregory Zilboorg (1929, 1941), and I then began to read the contributions of more recent practitioners, including, most especially, two American pioneers of psychoanalytical psychology, namely Professor Bertram Karon and Dr. Gary VandenBos (1981), whose jointly written textbook, Psychotherapy of Schizophrenia: The Treatment of Choice, remains, in my estimation, the most significant publication of all.

Fortified by these bold predecessors and by my own novice work with my very first patient, Steven, I soon began to treat many more individuals who had received a diagnosis of schizophrenia and who had spent years, if not decades, in psychiatric hospitals.

Although I cannot do justice to these early psychoanalytical clinical experiences in the context of such a brief communication, I can report that in every case, the mere act of sitting quietly in a room several times per week, and listening, and making occasional interpretations of the potential meanings of symptoms, allowed these people to unearth and to reveal very ugly traumatic experiences, which had tarnished their childhoods and their adulthoods, and which had made them feel extremely unsafe in the world. And, as treatment progressed, all of these troubled schizophrenic patients began to experience some sense of hope and understanding and, in consequence, became less overtly mad, so much so that many would ultimately be released from hospital and would no longer be required to consume large doses of antipsychotic medication.

Although the psychoanalytical approach to the understanding and treatment of schizophrenia still evokes considerable suspicion among many members of the mental health profession, particularly psychiatrists and experimental psychopathologists (e.g., Torrey, 1983; Kendler & Prescott, 2006), numerous colleagues, especially those in North America, have demonstrated that the talking cure boasts the tremendous potential to alleviate schizophrenic symptomatology with great success (e.g., Semrad, 1966; Boyer, 1967, 1975; Eldred, 1972; Freeman, 1975; Whitehorn & Betz, 1975; Arieti, 1976, 1980; Spotnitz, 1976; Bruch, 1978; Gunderson, 1979; Liegner, 1980; Stone, 1983; Magid, 1984; Benedetti, 1987; Karon, 1987, 1992; Strean & Freeman, 1990; Nagel, 1991; Müller, 2006; Rockland,

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2010; Bollas, 2015). Alas, in spite of the fact that many of our psychoanalytically oriented colleagues have made great strides in documenting their clinical work, very few have dared to theorize systematically about the etiology of schizophrenia from a Freudian perspective.

In the mid-1980s, I spent a year in the United States on a fellowship, during which time I had the privilege of meeting and interviewing two extraordinary senior figures on a number of occasions. The late Professor Flora Rheta Schreiber (1973), a psychoanalytically oriented academic, had authored several landmark books, such as Sybil—the true story of a much-abused girl who became extremely dissociative in later life—and also The Shoemaker: The Anatomy of a Psychotic (Schreiber, 1983; cf. Arieti & Schreiber, 1981), a study of the inner world of Joseph Kallinger, a notorious American multiple murderer, whom Schreiber interviewed across many years, tracing the roots of his psychotic and forensic state back to his exceptionally cruel childhood. I also enjoyed the great pleasure of working with the noted psychoanalyst Professor William Niederland (1974), a German-born émigré, who had studied the childhood of Daniel Paul Schreber in tremendous detail. Bill Niederland, a practicing clinician, who had trained at the New York Psychoanalytic Institute, underscored the importance of physical abuse as an etiological factor in the development of schizophrenia. Few colleagues in the 1980s truly recognized the importance of the research of Bill Niederland and Flora Schreiber, but as I came to know each of these esteemed figures, I began to appreciate more and more the vital significance of their discoveries that psychotic patients had endured a great deal of documentable abuse of a physical and a sexual nature.

I also had the opportunity to speak to the iconic Swiss psychoanalyst, Dr. Alice Miller, who, without hesitation, told me that in her experience, fully 100% of all schizophrenic patients have suffered, unquestionably, from sexual abuse.

We must remember that although sexual traumata have become, nowadays, a much more familiar and much more digestible topic among mental health professionals, back then, in the 1980s, very few psychiatrists or psychologists had written about this subject with any degree of explicitness (cf. deMause, 1974; Herman & Hirschman, 1981), and many psychoanalysts subscribed to the notion that Freud had abandoned the so-called “seduction theory” in favor of an Oedipal theory (Masson, 1984); therefore, few believed that physical abuse or sexual abuse actually contributed to the development of the psychoses.

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I suspect that Schreiber and Niederland and Miller might be rather surprised and relieved to know that nowadays, even the more traditional, non-psychoanalytically disposed mental health professionals have come to appreciate the role of physical abuse and sexual abuse in the early life histories of our psychotic patients (e.g., Read et al., 2004; Read & Hammersley, 2005, 2006; Read et al., 2005; Read et al., 2006; Read & Gumley, 2008; Cutajar et al., 2010; Bebbington et al., 2011; Fisher et al., 2014).

Nevertheless, in spite of the growing recognition of the etiological role of trauma, not all of our schizophrenic patients will have experienced bodily assaults by any means, and, moreover, most people who have suffered corporeal abuse—whether physical or sexual or both—will not invariably become schizophrenic. Therefore, although physical abuse and sexual abuse may be regarded as contributory factors, they do not, in my estimation, serve as the primary causes of the psychoses, especially the schizophrenic psychoses.

Spurred by the warm encouragement that I had received from Flora Schreiber and Bill Niederland, and also from Alice Miller, I began to explore my own growing caseload more fully. Certainly, my inaugural patient, Steven, had endured both physical abuse and sexual abuse from family members and also from strangers throughout his childhood. Undoubtedly, these experiences exerted a huge negative impact and contributed to his sense of persecution and, moreover, to his wish to die.

But Steven also suffered from another type of abuse, which did not involve physical contact of an intrusive nature. In addition to those more palpable traumata, he also experienced parental death threats.

Throughout our work, I discovered that on many occasions, Steven’s very angry mother used to chase him around the family home with a knife, threatening to stab him to death. Strikingly, while studying Steven’s old case notes from the 1960s, buried in the hospital archives, I unearthed a dust-covered clinical assessment report written by the psychiatrist who had first admitted Steven to the in-patient ward, years previously, after having actually paid a home visit and having encountered the mother with a knife clutched very visibly in her hands. So, I had discovered some very strong forensic evidence to support Steven’s memory of being hunted by his weapon-bearing mother.

Thus, Steven endured physical abuse, sexual abuse, and, furthermore, a series of actual death threats. No wonder he found the very atmosphere of the world so terrifying that he lapsed into catatonic states and pretended to be dead already (Kahr, 2012).

As I immersed myself more and more into the private life stories of schizophrenic patients, I came to discover that in every single case, these suffering men and women had to endure not only the more traditional forms of physical, sexual, and emotional abuse, but also death threats and death wishes of a very sinister nature. By 1993, I had accumulated enough clinical data to propose three separate categories of death threats towards pre-schizophrenic children (Kahr, 1993).

In the first category, I identified children and young people, such as Steven, who had experienced actual deadly attacks, such as being chased by his knife-wielding mother, who kept screaming that she hoped that he would die.

In the second category, I studied patients who had endured particular psychological difficulties as a result of having entered the world as so-called “replacement children.” For instance, one patient, “Miss B.,” born precisely nine months after the death of a sister (who had succumbed to diphtheria), had to cope with being a mere replacement for her much beloved dead sibling. Shockingly, the parents chose the very same forename for Miss B. that they had given to her deceased sister several years previously. Thus, Miss B. grew up knowing that her parents wished that she had died, not the elder sibling. Miss B. became severely schizophrenic and spent day after day on the hospital ward laughing hebephrenically and drooling saliva all over herself. Additionally, she would lapse into both catatonic and paranoid states on a frequent basis.

Finally, in the third category of death wish or death threat, I identified a cohort of patients whose parents (generally the mothers) had attacked them verbally during early childhood by explaining that had they not grown up in highly religious (often Catholic) families, they would have aborted their babies if possible. One of my patients, “Miss C.,” recalled that during her childhood, the mother often lambasted her hatefully, “You know, I really wanted to have an abortion when I was pregnant with you, but my gynecologist was a really strict Catholic, and he wouldn’t let me.”

I positioned these discrete, but interrelated, types of death wishes as expressions of what I came to describe as “psychological infanticide” (Kahr, 1993, p.269). In other words, unlike those cases of actual forensic infanticide, in which the mother or father successfully murders the baby, in cases of psychological infanticide, the child remains alive physiologically, but killed off emotionally, knowing that his or her parents had harbored profound sadistic wishes. I thus advanced the somewhat shocking notion 18

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that an infanticidal psychological death wish, often combined with forensic physical or sexual abuse, may well be key factors that stimulate breakdowns and result in the development of a schizophrenic psychosis.

I must confess that during the 1990s, when I first began to lecture on this topic, colleagues experienced this type of clinical material as very unpleasant. On one occasion, in the midst of a public talk about my work, a rather senior psychoanalyst stormed out of the room and then apologized to me afterwards, exclaiming, “I’m sorry, Brett. It’s just too horrible to hear about parents wishing their children dead.”

Fortunately, my students and my supervisees, most of whom had begun their training long after child abuse had become a part of regular clinical discourse, proved to be far more receptive to such ugly ideas, and many revealed similar psychologically infanticidal experiences in their own burgeoning work with psychotic patients.

Of course, the notion of the parental death wish has infiltrated the psychoanalytical literature since the very outset. The young Dr. Sigmund Freud (1900, p.176) wrote about the “Todeswunsch,” translated as the “death wish,” in his classic turn-ofthe-century masterpiece Die Traumdeutung, better known in English as The Interpretation of Dreams (Freud, 1900/1953). The father of psychoanalysis, however, focused predominantly on the death wishes of children towards their parents (or siblings), rather than upon the death wishes of parents towards their own offspring. Dr. Donald Winnicott (1949) expanded Freud’s work in his now classic paper “Hate in the CounterTransference,” exploring the ubiquity of parental hatred towards babies; but he did not investigate maternal or paternal death wishes as an etiological factor in the development of the psychoses per se. Winnicott’s foregrounding of maternal death wishes proved very upsetting to some of his colleagues, one of whom, the late Dr. Colin James (1991)—a prominent London-based psychoanalyst and group analyst—even spoke quite publicly about his tremendous sense of shock upon having first encountered such disturbing ideas.

Inspired by the challenging, blue-sky work of Freud and Winnicott regarding the reality of death wishes, and by the contributions of Niederland, Schreiber, and others on the role of trauma in schizophrenia, I began to accumulate more clinical material, not only from my own psychoanalytical practice, but also from the psychotherapeutic treatments conducted by my trainees, who, as a result of our supervisory and classroom conversations, had become, in my estimation, much more sensitive to the possibility of parental death wishes. Before

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long, with the growth of the internet, several schizophrenic outpatients had begun to learn of my work and had even requested psychological consultations, assuring me that maternal and paternal death threats did exist and did, indeed, contribute substantially to their own breakdowns.

In due course, I came to identify not only many more cases of schizophrenia that involved death threats, death attacks, and death pronouncements (e.g., direct expressions of a wish to have one’s fetus aborted), but I also encountered numerous psychotic patients who had experienced other variants of psychological infanticide.

For instance, I began to work with a series of men and women whose parents had murdered their childhood cats or dogs or who had forced their sons or daughters to watch these small animals being killed. One of my patients, a woman called “Catherine,” told me that when she was six, her father became so enraged at one point that he bundled up three small kittens into a sack and threw them into the river near the family home, while Catherine watched in horror as these little felines drowned.

Strikingly, Catherine developed paranoid schizophrenia in later life. She also told me that throughout her childhood, everyone called her “Cat” or “Catty”—abbreviations of “Catherine” —and that at times, she could not differentiate between the drowning of the three kittens and her own anticipated death at the hands of her father.

I conceptualized this sort of relationship between a pet-killing parent and a terrified child as the “Infanticidal Attachment” (Kahr, 2007a, p.119), thus rendering more explicit the nature of the relationality of these experiences of intergenerational deadliness (cf. Kahr, 2007b).

As the next tranche of my clinical practice unfolded, I continued to work with psychotic patients and also with forensic patients, having had the privilege of serving as a member of the treatment team at the Tavistock Clinic’s Young Abusers Project, providing assessments and psychoanalytical psychotherapy for juvenile pedophiles (e.g., Kahr, 2004). These individuals likewise reported horrific stories of family murderousness, although, in many instances, the forensic perpetrators had witnessed the enactment of death wishes towards someone else, rather than towards themselves. One of my pedophile patients reported that although his mother had treated him rather cruelly for much of his childhood, she absolutely hated the father even more, and one day, in the midst of a very ugly row witnessed by the child, she raised a knife over the father’s head. Shockingly, the father collapsed from an immediate coronary attack and died within minutes. My patient thus experienced

a deferred death threat. He did not become schizophrenic in later life, but he did develop into a full-fledged pedophile, and used his knife-like penis to harm the bodies of many little girls (Kahr, 2004, 2020a).

It became increasingly apparent that as victims of severe death threats, children would be more likely to develop schizophrenia years hence, while those recipients of less severe threats—as in the case of the aforementioned juvenile pedophile—would be more likely to become predominantly forensic, rather than fully psychotic (recognizing, of course, that the most extremely ill and abused of our patients can often inhabit both states of mind [Kahr, 2020b]).

I also became aware that parental death wishes will be transmitted, as Winnicott (1949) had suggested, in the most ordinary way; but if such dreadful emotions could be contained by the mother or father, those powerful wishes did not always result in the development of extreme psychopathology.

For instance, one of my severely neurotic patients told me that her mother used to joke that if the family home should ever catch on fire, she would probably save her husband first so that she could then produce more children. This “joke” terrified my patient, but she did not become psychotic in later life, perhaps, in part, because this expression of hatred sat alongside considerable caregiving and affection as well, qualities often lacking in the childhoods of the more overtly psychotic individuals.

The heaving topic of conscious and unconscious death wishes in parent-infant relationships cannot be explored fully in the context of such a modest-length communication. I have, however, examined this matter in additional publications, which may be of interest to colleagues (e.g., Kahr, 1993, 1994, 2001, 2007a, 2007b, 2012, 2013, 2016, 2019, 2020a). But in this short report, I wish merely to emphasize a few basic points: The etiology of schizophrenia remains a topic of tremendous controversy among contemporary mental health practitioners.

But we must appreciate that even those

1. In spite of the longstanding claims of biomedical scientists, we still have no compelling evidence that schizophrenic psychoses result predominantly from genetic and biochemical factors.

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2. We do, however, boast powerful clinical and empirical data that schizophrenia can be treated successfully by traditional psychoanalytical interventions, albeit over a lengthy period of time.

3. We now have a deeper obligation to our patients to explore etiological factors in the development of cases of schizophrenia even more fully, examining not only physical and sexual trauma, but also emotional trauma.

4. In this regard, I wish to foreground an old, but still poorly investigated concept, namely the Todeswunsch [“death wish”], as a potentially causal ingredient in the development of schizophrenia and other forms of psychopathology.

5. I urge colleagues to discuss and to document data about parental death wishes across the spectrum of psychopathology so that we may all become more adept at discussing such matters with our patients and with one another. who regard schizophrenia as a biomedical disease have come to recognize that family factors do contribute to the likelihood of a psychotic breakdown. Not only have traditional psychiatrists begun to acknowledge the causal role of physical abuse and sexual abuse, but moreover, several investigators, such as Professor Julian Leff and his colleagues, formerly of the Institute of Psychiatry at the University of London, have explored the impact of heightened,

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expressed emotion in families as an exacerbating factor in the development of schizophrenic remissions (e.g., Hirsch & Leff, 1971, 1975; Vaughan & Leff, 1976, 1981; Kuipers et al., 1992; Leff, 2001, 2002, 2005). Thus, family interactions now occupy an increasingly central position in our understanding of psychosis, and, moreover, so-called “pathogenic parenting” (Ferriter, 1999, p.1) may, in fact, be far more impactful than we often wish to acknowledge.

In thinking about the role of infant-parent relationships in the development of schizophrenia, we must be sensitive, and we must avoid blaming and shaming burdened and troubled mothers and fathers in a crude manner. But at the same time, we must curate the data honestly and comprehensively and validate the possibility that a parent might truly harbor murderous feelings towards a child, which could result in devastating psychological consequences.

Many years ago, I had the privilege of speaking with Professor Theodore Lidz, one of the true heroes of mid-twentieth-century American psychoanalysis, who, along with several astute colleagues, pioneered our understanding of the role of family dynamics in schizophrenia (e.g., Lidz et al., 1965). During the latter years of his life, Theodore Lidz, in collaboration with Professor Sidney Blatt—another pioneer of psychoanalytical psychology—dared to published various critiques of the so-called genetic data about schizophrenia (e.g., Lidz et al., 1981; Lidz, 1983; Lidz and Blatt, 1983a, 1983b). This work inspired me, and consequently, I wish to conclude this article with a reference to one of his vignettes, which, I believe, truly encapsulates the potential role of the death wish.

In his solo-authored book, The Origin and Treatment of Schizophrenic Disorders (1973), Lidz wrote about a young psychotic hospitalized patient who suffered hugely.

Lidz had the opportunity to meet this person’s mother, who soon revealed that her daughter nursed a great passion for the novels of Virginia Woolf. As Lidz explained, “Her mother hoped her daughter would follow in the footsteps of her idol. I hesitated before commenting, ‘But Virginia Woolf had psychotic episodes and committed suicide.’ The mother did not hesitate when she replied, ‘It would be worth it.’” (Lidz, 1973, pp.99-100).

Tragically, this young schizophrenic patient eventually committed suicide.

One need not be a psychoanalyst to appreciate the painful and frightening intensity of parental death wishes or of the child’s unconscious capacity to enact these murderous wishes in such a gut-wrenching and tragic manner. Death wishes—though often very invisible—really do exist, and they most certainly do wreak havoc in a psychologically contagious and viral manner. z 21

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COMMENTARIES AND TESTIMONIES REFERENCES Abraham, K. (1907). Über die Bedeutung sexueller Jugendtraumen für die Symptomatologie der Dementia praecox. Centralblatt für Nervenheilkunde und Psychiatrie, 30, 409-415.

Abraham, K. (1908). Die psychosexuelle Differenzen der Hysterie und der Dementia praecox. Zentralblatt für Nervenheilkunde und Psychiatrie, 31, 521-533.

Andral, G. (1833). Lectures on medical pathology, delivered in the University of Paris, by M. Andral: Mental alienation. The Lancet, 19 (488), pp.459-462.

Andreasen, N. C. (1984). The broken brain: The biological revolution in psychiatry. New York, NY: Harper and Row, Publishers.

Andreasen, N. C. (1986). Cerebral localization: Its relevance to psychiatry. In Nancy C. Andreasen (Ed.), Can schizophrenia be localized in the brain?, pp.3-16. Washington, DC: American Psychiatric Press.

Arieti, S. (1976). The psychotherapeutic approach to schizophrenia. In Dargut Kemali, Giuseppe Bartholini, and Derek Richter (Eds.), Schizophrenia today, pp.245-257.

Oxford, England: Pergamon Press.

Arieti, S. (1980). Psychotherapy of schizophrenia: New or revised procedures. American Journal of Psychotherapy, 34, 464-476.

Arieti, S., and Schreiber, F. R. (1981). Multiple murders of a schizophrenic patient: A psychodynamic interpretation.

Journal of the American Academy of Psychoanalysis, 9, 501-524.

Bebbington, P., Jonas, S., Kuipers, E., King, M., Cooper, C., Brugha, T., Meltzer, H., McManus, S., and Jenkins, R. (2011). Childhood sexual abuse and psychosis: Data from a cross-sectional national psychiatric survey in England.

British Journal of Psychiatry, 199, 29-37.

Benedetti, G. (1987). Psychotherapy of schizophrenia. New York, NY: New York University Press.

Berrios, G. E. (1991). Psychosurgery in Britain and elsewhere: A conceptual history. In German E. Berrios and Hugh Freeman (Eds.), 150 years of British psychiatry, 18411991, pp.180-196. London, England: Gaskell.

Berrios, G. E. (1996). Early electroconvulsive therapy in Britain, France and Germany: A conceptual history. In Hugh Freeman and German E. Berrios (Eds.), 150 years of British psychiatry: Volume II. The aftermath, pp.3-15. London, England: Athlone Press.

Berrios, G. E. (1997). The origins of psychosurgery: Shaw, Burckhardt and Moniz. History of Psychiatry, 8, 61-81.

Binion, R. (1986). After Christianity: Christian survivals in the post-Christian era. Durango, CO: Logbridge-Rhodes.

Bleckwenn, W. J. (1931). The use of sodium amytal in catatonia. In George H. Kirby, Thomas K. Davis, and Henry Alsop Riley (Eds.), Schizophrenia [dementia praecox]: An investigation of the most recent advances. The proceedings of the association, New York, December 27th and 28th, 1929, pp.224229. Baltimore, MD: Williams and Wilkins Company.

Bollas, C. (2015). When the sun bursts: The enigma of schizophrenia. New Haven, CT: Yale University Press.

Boyer, L. B. (1967). Office treatment of schizophrenic patients: The use of psychoanalytic therapy with few parameters. Introduction. In L. Bryce Boyer and Peter L. Giovacchini, Psychoanalytic treatment of characterological and schizophrenic disorders, pp.143-188. New York, NY: Science House.

Boyer, L. B. (1975). Treatment of characterological and schizophrenic disorders. In Peter L. Giovacchini, Alfred Flarsheim, and L. Bryce Boyer (Eds.), Tactics and techniques in psychoanalytic therapy, Vol. II: Countertransference, pp.341373. New York, NY: Jason Aronson.

Bruch, H. (1978). A historical perspective of psychotherapy in schizophrenia. In William E. Fann, Ismet Karacan, Alex D. Pokorny, and Robert L. Williams (Eds.), Phenomenology and treatment of schizophrenia, pp.311-324.

Jamaica, NY: Spectrum Publications.

Buklijas, T. (2008). Cultures of death and politics of corpse supply: Anatomy in Vienna, 1848-1914. Bulletin of the History of Medicine, 82, 570-607.

Carvajal, A., Arias, L. H. M., and Jimeno, N. (2009). Antipsychotic drugs. In Jeffrey K. Aronson (Ed.), Side effects of drugs annual 31: A worldwide yearly survey of new data and trends in adverse drug reactions and interactions, pp.65-104.

Amsterdam, Netherlands: Elsevier.

Colaizzi, J. (1989). Homicidal insanity, 1800-1985. Tuscaloosa, AL: University of Alabama Press.

Crow, T. J. (1978). The biochemistry of schizophrenia.

British Journal of Hospital Medicine, 20, 532, 537-538, 540, 544.

Crow, T. J. (1994). Prenatal exposure to influenza as a cause of schizophrenia: There are inconsistencies and

contradictions in the evidence. British Journal of Psychiatry, 164, 588-592.

Cutajar, M. C., Mullen, P. E., Ogloff, J. R. P., Thomas, S. D., Wells, D., and Spataro, J. (2010). Schizophrenia and other psychotic disorders in a cohort of sexually abused children. Archives of General Psychiatry, 67, 1114-1119. deMause, L. (1974). The evolution of childhood. In Lloyd deMause (Ed.), The history of childhood, pp.1-73. New York, NY: Psychohistory Press, Division of Atcom.

Eldred, S. H. (1972). Intensive psychotherapy with schizophrenic patients. Contemporary Psychoanalysis, 8, 149-164.

English, W. M. (1929). Report of the treatment with manganese chloride of 181 cases of schizophrenia, 33 of manic depression, and 16 of other defects or psychoses at the Ontario Hospital, Brockville, Ontario. American Journal of Psychiatry, 9, 569-579.

Ferriter, M. (1999). Schizophrenia and parenting.

Aldershot, England: Ashgate Publishing and Brookfield, VT: Ashgate Publishing Company.

Fink, M. (1999). Electroshock: Restoring the mind. New York, NY: Oxford University Press.

Fisher, H. L., McGuffin, P., Boydell, J., Fearon, P., Craig, T. K., Dazzan, P., Morgan, K., Doody, G. A., Jones, P. B., Leff, J.; Murray, R. M., and Morgan, C. (2014). Interplay between childhood physical abuse and familial risk in the onset of psychotic disorders. Schizophrenia Bulletin, 40, 1443-1451.

Fraser, R., and Sargant, W. (1940). Some points in the technique of insulin therapy of the psychoses. Journal of Mental Science, 86, 969-980.

Freeman, T. (1975). Schizophrenia from the psychoanalytical standpoint. In Alistair Forrest and James Affleck (Eds.), New perspectives in schizophrenia, pp.117-137.

Edinburgh, Scotland: Churchill Livingstone.

Freeman, W., and Watts, J. W. (1942). Psychosurgery: Intelligence, emotion and social behavior following prefrontal lobotomy for mental disorders. Springfield, IL: Charles C Thomas, Publisher.

Freeman, W., and Watts, J. W. (1944). Psychosurgery: An evaluation of two hundred cases over seven years. Journal of Mental Science, 90, 532-537.

Freud, S. (1900). Die Traumdeutung. Vienna, Austria: Franz Deuticke.

Freud, S. (1911). Psychoanalytische Bemerkungen über einen autobiographisch beschriebenen Fall von Paranoia (Dementia Paranoides). Jahrbuch für psychoanalytische und psychopathologische Forschungen, 3, 9-68.

Freud, S. (1937). Konstruktionen in der Analyse. Internationale Zeitschrift für Psychoanalyse, 23, 459-469.

Freud, S. (1950). (Manuskript H): Paranoia. In Marie Bonaparte, Anna Freud, and Ernst Kris (Eds.) Aus den Anfängen der Psychoanalyse: Briefe an Wilhelm Fliess, Abhandlungen und Notizen aus den Jahren 1887-1902, pp.118-124. London, England: Imago Publishing Company.

(Original work published 1895) Freud, S. (1953). The interpretation of dreams. In J. Strachey (Ed. and Trans.), Standard edition (Vol. 5, pp.ix-627). London, England: Hogarth Press. (Original work published 1900) Freud, S. (1966). Draft H: Paranoia. In J. Strachey (Ed. and Trans.), Standard edition (Vol. 1, pp.206-212). London, England: Hogarth Press. (Original work published 1895) Fromm-Reichmann, F. (1943). Psychoanalytic psychotherapy with psychotics: The influence of the modifications in technique on present trends in psychoanalysis. Psychiatry, 6, 277-279.

Fromm-Reichmann, F. (1947). Problems of therapeutic management in a psychoanalytic hospital. Psychoanalytic Quarterly, 16, 325-356.

Fromm-Reichmann, F. (1948). Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry, 11, 263-273.

Fromm-Reichmann, F. (1954). Psychotherapy of schizophrenia. American Journal of Psychiatry, 111, 410-419.

Fromm-Reichmann, F. (1955). Intuitive processes in the psychotherapy of schizophrenics: Introduction. Journal of the American Psychoanalytic Association, 3, 5-6.

Galen. (1656). Galen’s method of phy∫ick: Or, his great master-peece; being the very marrow and quinte∫∫ence of all his writings. Wherein he exceeds not only himself, but al∫o all others, on ∫uch a subject, being not only ∫ufficient thorowly to acquaint any judicious man with all the principles of phy∫ick or medicine, but al∫o it is ab∫olutely nece∫∫ary for directing all practitioners in all their phy∫icall applications and cures. Whereto is annexed a ∫uccinct and plain commentary for explaining the difficulties thereof Peter English (Transl.). Edinburgh, Scotland: A. A. for George Suintoun and James Glen, Stationers.

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DIVISION | R E V I E W

Galen. (2013). Galen: Psychological writings Peter N. Singer (Ed.), Vivian Nutton, Daniel Davies, Peter N. Singer, and Piero Tassinari (Transl.). Cambridge, England: Cambridge University Press.

Gilman, S. L. (1982). Seeing the insane. New York, NY: John Wiley and Sons, in association with Brunner/Mazel Publishers.

Gilman, S. L. (1984). Jews and mental illness: Medical metaphors, anti-Semitism, and the Jewish response. Journal of the History of the Behavioral Sciences, 20, 150-159.

Gilman, S. L. (2008). Electrotherapy and mental illness: Then and now. History of Psychiatry, 19, 339-357.

Gottesman, I. I., and Shields, J. (1972). Schizophrenia and genetics: A twin study vantage point. New York, NY: Academic Press.

Graham, T. F. (1967). Medieval minds: Mental health in the Middle Ages. London, England: George Allen and Unwin.

Gunderson, J. G. (1979). Individual psychotherapy. In Leopold Bellak (Ed.), Disorders of the schizophrenic syndrome, pp.364-398. New York, NY: Basic Books.

Herman, J. L., and Hirschman, L. (1981). Father-daughter incest. Cambridge, MA: Harvard University Press.

Hill, H. (1938). Histamine and insulin in the treatment of schizophrenia and other mental diseases. Journal of Mental Science, 84, 581-588.

Hill, H. (1940). The histamine and insulin treatment of schizophrenia and other mental diseases. London, England: Baillière, Tindall and Cox. Hirsch, S. R., and Leff, J. P. (1971). Parental abnormalities of verbal communication in the transmission of schizophrenia. Psychological Medicine, 1, 118-127.

Hirsch, S. R., and Leff, J. P. (1975). Abnormalities in parents of schizophrenics: A review of the literature and an investigation of communication defects and deviances. London, England: Oxford University Press.

Jackson, S. W. (1969). Galen: On mental disorders.

Journal of the History of the Behavioral Sciences, 5, 365-384.

James, D. C. (1991). Lecture on “On Winnicott’s “Fear of Breakdown” ”. Conference on “Contributions of Donald Winnicott”. The British Psycho-Analytical Society, London, at the Cavendish Conference Centre, London, England. 2nd March.

Jones, M. (1940). Intravenous insulin in the treatment of schizophrenia. The Lancet, 236(6108), p.361.

Kahr, B. (1993). Ancient infanticide and modern schizophrenia: The clinical uses of psychohistorical research. Journal of Psychohistory, 20, 267-273.

Kahr, B. (1994). The historical foundations of ritual abuse: An excavation of ancient infanticide. In Valerie Sinason (Ed.), Treating survivors of satanist abuse, pp.45-56.

London, England: Routledge.

Kahr, B. (2001). The legacy of infanticide. Journal of Psychohistory, 29, 40-44.

Kahr, B. (2004). Juvenile paedophilia: The psychodynamics of an adolescent. In Charles W. Socarides and Loretta R. Loeb (Eds.), The mind of the paedophile: Psychoanalytic perspectives, pp.95-119. London, England: H. Karnac (Books).

Kahr, B. (2007a). The infanticidal attachment.

Attachment: New directions in psychotherapy and relational psychoanalysis, 1, 117-132.

Kahr, B. (2007b). The infanticidal attachment in schizophrenia and dissociative identity disorder.

Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, 1, 305-309.

Kahr, B. (2012). The infanticidal origins of psychosis: The role of trauma in schizophrenia. In Judy Yellin and Kate White (Eds.), Shattered states: Disorganised attachment and its repair. The John Bowlby Memorial Conference Monograph 2007, pp.7-126. London, England: Karnac Books.

Kahr, B. (2013). When Daddy kills the dog: Pet murder and the infanticidal attachment. Unpublished typescript.

Kahr, B. (2016). “Happy birthdeath to me”: Surviving death wishes in early infancy. In Stella Acquarone (Ed.), Surviving the early years: The importance of early intervention with babies at risk, pp.57-84. London, England: Karnac Books.

Kahr, B. (2019). ‘Slashing the teddy bear’s tummy with a carving knife’: The infanticidal roots of schizophrenia.

British Journal of Psychotherapy, 35, 399-416.

Kahr, B. (2020a). Bombs in the consulting room: Surviving psychological shrapnel. London, England and Abingdon, England: Routledge/Taylor and Francis Group.

Kahr, B. (2020b). Dangerous lunatics: Trauma, criminality, and forensic psychotherapy. London, England: Confer Books.

Kallmann, F. J. (1946). The genetic theory of schizophrenia: An analysis of 691 schizophrenic twin index families. American Journal of Psychiatry, 103, 309-322.

Kallmann, F. J., and Rypins, S. J. (1938). Schizophrenia:

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COMMENTARIES AND TESTIMONIES A study of heredity and reproduction in the families of 1,087 schizophrenics. New York, NY: J.J. Augustin Publisher.

Karon, B. P. (1987). The treatment of acute schizophrenic patients in private practice. British Journal of Psychotherapy, 4, 135-140.

Karon, B. P. (1992). The fear of understanding schizophrenia. Psychoanalytic Psychology, 9, 191-211.

Karon, B. P., and VandenBos, G. R. (1981). Psychotherapy of schizophrenia: The treatment of choice. New York, NY: Jason Aronson.

Katan, M. (1975). Childhood memories as contents of schizophrenic hallucinations and delusions. Psychoanalytic Study of the Child, 30, 357-374. Kendler, K. S., and Prescott, C. A. (2006). Genes, environment, and psychopathology: Understanding the causes of psychiatric and substance use disorders.

New York, NY: Guilford Press.

Kneeland, T. W., and Warren, C. A. B. (2002). Pushbutton psychiatry: A history of electroshock in America. Westport, CT: Praeger Publishers.

Kuipers, L., Leff, J., and Lam, D. (1992). Family work for schizophrenia: A practical guide. London, England: Gaskell/ Royal College of Psychiatrists.

Langfeldt, G. (1939). The schizophreniform states: A katamnestic study based on individual re-examinations.

Copenhagen, Denmark: Ejnar Munksgaard International Publisher and London, England: Oxford University Press.

Leff, J. (2001). The unbalanced mind. London, England: Weidenfeld and Nicolson.

Leff, J. (2002). Keynote lecture: Relatives’ expressed emotion: From measurement technique to practical help for families. In Kashima Haruo, Ian R. H. Falloon, Mizuno Masafumi, and Asai Masahiro (Eds.), Comprehensive treatment of schizophrenia: Linking neurobehavioral findings to psychosocial approaches, pp.83-93. Tokyo, Japan: SpringerVerlag.

Leff, J. (2005). Advanced family work for schizophrenia: An evidence-based approach. London, England: Gaskell.

Levitt, R. A. (1975). Psychopharmacology: A biological approach. Washington, D.C.: Hemisphere Publishing Corporation, and New York, NY: Halsted Press/John Wiley and Sons.

Lewis, M., McCrone, P., and Frangou, S. (2001). Service use and costs of treating schizophrenia with atypical antipsychotics. Journal of Clinical Psychiatry, 62, 749-756.

Lidz, T. (1973). The origin and treatment of schizophrenic disorders. New York, NY: Basic Books.

Lidz, T. (1983). Danish data show weak genetic factor.

American Journal of Psychiatry, 141, 1308.

Lidz, T., and Blatt, S. (1983a). Critique of the DanishAmerican studies of the biological and adoptive relatives of adoptees who became schizophrenic. American Journal of Psychiatry, 140, 426-435.

Lidz, T., and Blatt, S. (1983b). Drs. Lidz and Blatt on Dr. Kety’s review. American Journal of Psychiatry, 140, 963-964.

Lidz, T., Blatt, S., and Cook, B. (1981). Critique of the Danish-American studies of the adopted-away offspring of schizophrenic parents. American Journal of Psychiatry, 138, 1063-1068.

Lidz, T., Fleck, S., and Cornelison, A. (1965).

Schizophrenia and the family. New York, NY: International Universities Press.

Liegner, E. J. (1980). The hate that cures: The psychological reversibility of schizophrenia. Modern Psychoanalysis, 5, 5-95.

Lombroso, C. (1876). L’Uomo delinquente: Studiato in rapporto alla antropologia, alla medicina legale ed alle discipline carcerarie. Milan, Italy: Ulrico Hoepli, Libraio-Editore.

Magid, B. (1984). Some contributions of self psychology to the treatment of borderline and schizophrenic patients.

Dynamic Psychotherapy, 2, 101-111.

Masson, J. M. (1984). The assault on truth: Freud’s suppression of the seduction theory. New York, NY: Farrar, Straus and Giroux.

Maudsley, H. (1868). Illustrations of a variety of insanity. Journal of Mental Science, 14, 149-162.

McConnell, J. (1945). Two years’ experience of female schizophrenics treated by insulin coma therapy. Journal of Mental Science, 91, 506-510.

McGregor, J. S., and Crumbie, J. R. (1941). Surgical treatment of mental diseases. The Lancet, 238(6149), pp.7-8.

McGregor, J. S., and Crumbie, J. R. (1942). Prefrontal leucotomy. Journal of Mental Science, 88, 534-540.

Moniz, E. (1936). Tentatives opératoires dans le traitement de certaines psychoses. Paris, France: Masson et Compagnie, Éditeurs.

Müller, C. (2006). Beginnings of the international symposia for the psychotherapy of schizophrenia. In Yrjö Alanen, Ann-Louise S. Silver, and Manuel González de

Chávez (Eds.), Fifty years of humanistic treatment of psychoses: In honour of the history of the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses, 1956-2006, pp.23-29. Madrid, Spain: Fundación para la Investigación y Tratamiento de la Esquizofrenia y otras Psicosis.

Nagel, D. B. (1991). Psychotherapy of schizophrenia: 1900-1920. In John G. Howells (Ed.), The concept of schizophrenia: Historical perspectives, pp.191-201.

Washington, D.C.: American Psychiatric Press.

Niederland, W. G. (1959a). The “miracled-up” world of Schreber’s childhood. Psychoanalytic Study of the Child, 14, 383-413.

Niederland, W. G. (1959b). Schreber: Father and son.

Psychoanalytic Quarterly, 28, 151-169.

Niederland, W. G. (1963). Further data and memorabilia pertaining to the Schreber case. International Journal of Psycho-Analysis, 44, 201-207.

Niederland, W. G. (1974). The Schreber case: Psychoanalytic profile of a paranoid personality. New York, NY: Quadrangle/New York Times Book Company.

Niederland, W. G. (1984). The Schreber case: Psychoanalytic profile of a paranoid personality, expanded edition. Hillsdale, New Jersey: Analytic Press.

Nutton, V. (2013). Galenic madness. In William V. Harris (Ed.), Mental disorders in the classical world, pp.119127. Leiden, Netherlands: Brill.

Parker, C. S. (1940). Observations on the autonomic functions during the hypoglycaemic treatment of schizophrenics. Journal of Mental Science, 86, 645-659.

Read, J., Goodman, L., Morrison, A. P., Ross, C. A., and Aderhold, V. (2004). Childhood trauma, loss and stress.

In John Read, Loren R. Mosher, and Richard P. Bentall (Eds.), Models of madness: Psychological, social and biological approaches to schizophrenia, pp.223-252. Hove, England: Brunner-Routledge.

Read, J., and Gumley, A. (2008). Can attachment theory help explain the relationship between childhood adversity and psychosis? Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, 2, 1-35.

Read, J., and Hammersley, P. (2005). Child sexual abuse and schizophrenia. British Journal of Psychiatry, 186, 76.

Read, J., and Hammersley, P. (2006). Can very bad childhoods drive us crazy?: Science, ideology and taboo.

In Jan Olav Johannessen, Brian V. Martindale, and Johan Cullberg (Eds), Evolving psychosis: Different stages, different treatments, pp.270-292. Hove, England: Routledge.

Read, J., Rudegeair, T., and Farrelly, S. (2006). The relationship between child abuse and psychosis: Public opinion, evidence, pathways and implications. In Warren Larkin and Anthony P. Morrison (Eds.), Trauma and psychosis: New directions for theory and therapy, pp.23-57.

Hove, England: Routledge.

Read, J., van Os, J., Morrison, A. P., and Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications.

Acta Psychiatrica Scandinavica, 112, 330-350.

Rockland, L. H. (2010). Psychotherapeutic and psychosocial interventions in schizophrenia: Clinical outcomes and cost-effectiveness. In Susan G. Lazar (Ed.), Psychotherapy is worth it: A comprehensive review of costeffectiveness, pp.31-60. Arlington, VA: American Psychiatric Press.

Rosenfeld, H. (1947). Analysis of a schizophrenic state with depersonalization. International Journal of PsychoAnalysis, 28, 130-139.

Rosenfeld, H. (1949). Remarks on the relation of male homosexuality to paranoia, paranoid anxiety and narcissism.

International Journal of Psycho-Analysis, 30, 36-47.

Rosenfeld, H. (1950). Note on the psychopathology of confusional states in chronic schizophrenias. International Journal of Psycho-Analysis, 31, 132-137.

Rosenfeld, H. (1952). Notes on the psycho-analysis of the super-ego conflict of an acute schizophrenic patient.

International Journal of Psycho-Analysis, 33, 111-131.

Rosenfeld, H. A. (1969). Le Besoin d’acting out durant l’analyse chez les patients névrosés et psychotiques (Georges-Philippe Brabant, Transl.). Bulletin de l’Association Psychanalytique de France, 5, 179-193.

Rosenfeld, H. (1976). The treatment of psychotic states, particularly schizophrenia, by psychoanalysis. In Dargut Kemali, Giuseppe Bartholini, and Derek Richter (Eds.), Schizophrenia today, pp.259-270. Oxford, England: Pergamon Press.

Rosenfeld, H. (1987). Impasse and interpretation: Therapeutic and anti-therapeutic factors in the psychoanalytic treatment of psychotic, borderline, and neurotic patients.

London, England: Tavistock Publications.

23

DR2020_#23.indd 23

DIVISION | R E V I E W

Sandison, R. A., and McGregor, J. S. (1942). A year’s experience of intravenous insulin in the hypoglycaemic shock treatment of schizophrenia. Journal of Mental Science, 88, 387-406.

Schreiber, F. R. (1973). Sybil. Chicago, IL: Henry Regnery Company.

Schreiber, F. R. (1983). The shoemaker: The anatomy of a psychotic. New York, NY: Simon and Schuster.

Segal, H. (1950). Some aspects of the analysis of a schizophrenic. International Journal of Psycho-Analysis, 31, 268-278.

Segal, H. (1956). Depression in the schizophrenic.

International Journal of Psycho-Analysis, 37, 339-343.

Segal, H. (1972). A delusional system as a defence against the re-emergence of a catastrophic situation.

International Journal of Psycho-Analysis, 53, 393-401.

Segal, H. (1975). Psycho-analytical approach to the treatment of schizophrenia. In Malcolm H. Lader (Ed.), Studies of schizophrenia: Papers read at the World Psychiatric Association Symposium, “Current Concepts of Schizophrenia”, London, November 1972, pp.94-97. Ashford, England: Headley Brothers.

Segal, H. M. (1994). Paranoid anxiety and paranoia.

In John M. Oldham and Stanley Bone (Eds.), Paranoia: New psychoanalytic perspectives, pp.17-26. Madison, CT: International Universities Press.

Semrad, E. V. (1966). Long-term therapy of schizophrenia: Formulation of the clinical approach. In Gene L. Usdin (Ed.), Psychoneurosis and schizophrenia, pp.155-173. Philadelphia, PA: J.B. Lippincott Company.

Shakespeare, W. (n.d.) The tragedie of Hamlet, prince of Denmark. (Original work published 1623).

Shorter, E. (1997). A history of psychiatry: From the era of the asylum to the age of Prozac. New York, NY: John Wiley and Sons.

Shorter, E., and Healy, D. (2007). Shock therapy: A history of electroconvulsive treatment in mental illness. New Brunswick, NJ: Rutgers University Press.

Spotnitz, H. (1976). Psychotherapy of preoedipal conditions: Schizophrenia and severe character disorders. New York, NY: Jason Aronson.

Stone, M. H. (1983). The history of the psychoanalytic treatment of schizophrenia: The early period. In Michael H. Stone, Harry D. Albert, David V. Forrest, and Silvano Arieti (Eds.), Treating schizophrenic patients: A clinico-analytical approach, pp.65-92. New York, NY: McGraw-Hill Book Company.

Strean, H. S., and Freeman, L. (1990). The severed soul: A psychoanalyst’s heroic battle to heal the mind of a schizophrenic.

New York, NY: St. Martin’s Press.

Tennent, T. (1944). Insulin therapy. Journal of Mental Science, 90, 465-485.

Thomas, K. (1971). Religion and the decline of magic: Studies in popular beliefs in sixteenth and seventeenth century England. London, England: Weidenfeld and Nicolson.

Torrey, E. F. (1983). Surviving schizophrenia: A family manual. New York, NY: Harper and Row, Publishers.

Valenstein, E. S. (1986). Great and desperate cures: The rise and decline of psychosurgery and other radical treatments for mental illness. New York, NY: Basic Books.

Vaughn, C. E., and Leff, J. P. (1976). The Influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients. British Journal of Psychiatry, 129, 125-137.

Vaughn, C. E., and Leff, J. P. (1981). Patterns of emotional response in relatives of schizophrenic patients.

Schizophrenia Bulletin, 7, 43-44. von Krafft-Ebing, R. (1895). Nervosität und neurasthenische Zustände. In Hermann Nothnagel (Ed.), Specielle Pathologie und Therapie: XII. Band, II. Theil.

Nervosität und neurasthenische Zustände von Prof. Dr. R. v.

Krafft-Ebing, pp.v-210. Vienna, Austria: Alfred Holder.

Walsh, J. J. (1929). The history of nursing. New York, NY: P.J. Kenedy and Sons Publishers.

Whitehorn, J. C., and Betz, B. (1975). Effective psychotherapy with the schizophrenic patient. New York, NY: Jason Aronson.

Wilcox, P. H. (1947). Electroshock therapy: A review of over 23,000 treatments using unidirectional currents.

American Journal of Psychiatry, 104, 100-112.

Winnicott, D. W. (1949). Hate in the countertransference. International Journal of Psycho-Analysis, 30, 69-74.

Zilboorg, G. (1929). The dynamics of schizophrenic reactions related to pregnancy and childbirth. American Journal of Psychiatry, 8, 733-766.

Zilboorg, G. (1941). Ambulatory schizophrenias.

Psychiatry, 4, 149-155.

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In Conversation: A Dialogue on Psychosis, Psychoanalysis, and the Peer/Survivor Movement with Claire Bien and Marie Brown The following conversation stemmed from the discussants’ mutual interest in the intersection between peer support and psychoanalysis and their study of the work of Jean-Max Gaudillière and Françoise Davoine through a monthly reading group on Madness and the Social Link: The JeanMax Gaudillière Seminars (1985 – 2000).

Brown: As a person with lived experience of what is commonly called “psychosis,” what has drawn you to be interested in psychoanalysis?

Bien: What drew me to psychoanalysis was the positive experience I had with the very first therapist I ever saw, a thirdyear Harvard psychiatric resident at the Massachusetts Mental Health Center in Boston. She helped me enormously at a time when I was deeply, deeply unhappy.

Even though she didn’t do intensive psychoanalysis in our work together (and we did work together), her psychoanalytical background—an inherent part of her psychiatric training—informed all of our interactions. Working with her allowed me to explore how I experienced the world and seek to understand the role that my thoughts, beliefs, and expectations of myself and others influenced how I responded to, and often acted in, the world. One does not engage in such deep work without it becoming an integral part of oneself and one’s practice. As a result, I have always preferred seeing psychiatrists, who encourage me to explore thought, feeling, motivation, context, and understanding given my experiences and my perspectives on who I am and who I wish to be. I also like having the ability to ramble, with occasional observations that prompt further reflection and allow me to arrive at my understandings, with affirmation, rather than being subjected to what sometimes feels like intrusive or directive action.

The psychotherapeutic tradition of exploring the nature and sources of the varying traumas and hurts I’ve experienced throughout my life has also been important in my ability to reclaim my capacity to feel and to think independently, unhampered by the fear that the ideas that come when I am engaged in conversation with intelligent others might somehow expose a perspective or a history that would betray the people I love. I would say that I have arrived at that degree of self-understanding not only through those years of intermittent psychotherapy, but also from a wide

reading of the works of great western literature, along with western children’s classics, including fairy tales and fables and Greek, Roman, and Norse mythology. Literature captures beautifully and evocatively the heart, mind, and spirit of a people of an age.

I have long held the belief that great novelists are among the best psychologists—to be able to observe, understand, and comment on familial, social, institutional societal, and governmental politics requires a deep understanding of psychology. That’s why I so love the monthly Saturday afternoon conversations of the work of Jean-Max Gaudillière and Françoise Davoine.

I should add that my favorite psychologists in graduate school in counseling psychology included Carl Rogers, Alfred Adler, Erik Erikson, and Karen Horney, all trained in psychoanalysis. They seemed to me, when I read them, to be “common sense” psychologists. And, of course, Freud and Jung. One of the independent studies I did while in graduate school was comparing and contrasting the works of Freud and Jung (the other was on Adler, Erikson, and Horney). At the time (I was young!), I greatly admired Freud and found little to no resonance with Jung.

Given that I now think that Jung was right, the result of my lived experiences, I’m slightly mystified by my attitude. But I shouldn’t be mystified—we can’t know what we’ve never been exposed to or experienced. I’d like to note that my shift in perspective exemplifies the importance of life experience of lived expertise—one of the core understandings of the peer movement.

I should also note that I didn’t always love therapy, and especially not psychoanalytical approaches to psychotherapy.

When I first began seeing Dr. “Miller” at Massachusetts Mental Health Center, I walked out of her office the week she persuaded me to start exploring my relationship with my mother. Because I confessed to feeling anger and resentment toward Mother, I felt I had betrayed her, and I blamed Dr. Miller for this betrayal. It took three weeks for me to forgive Dr. Miller and go back to therapy. But I did go back. As a result, I was able to come to terms with my feelings toward Mother.

Brown: That’s so interesting; it sounds like your experiences of the mental health system, or more specifically, psychiatry, were very much of a time when psychoanalysis and humanistic approaches dominated the scene. What drew you to peer support?

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Bien: I became involved with the peer movement by serendipitous accident when my employer sent me to the organizational meetings of the New Haven affiliate of the National Alliance on Mental Illness (NAMI).

It was 2009, 26 years after I first began hearing voices. I had maintained a stoic silence about my psychiatric history and hospitalizations for those 26 years, in part because of stigma and in part because each time my life was significantly disrupted, I got better with love and support and moved on, mostly “forgetting” about my hospitalizations and diagnoses. I gave birth to a wonderful son who continues to do wonderfully, and I’m still friendly with my now ex-husband and his family, who were always supportive and kind. I should add that I have been unmedicated for 35 of the 37 years since I was first diagnosed. Many would say it’s mostly that that saved me. I would agree.

But at those early NAMI Elm City meetings, I met so many people with lived experience as well as family members who spoke bravely and poignantly of their feelings of fear, confusion, doubt, anger, and loss that I decided it was time to break the silence. I wanted people to know that it is possible to live a full life, to have a satisfying career, a family, a community into which one is fully integrated even while experiencing serious mental health challenges, including hearing voices and experiencing other unusual phenomena. I began writing my memoir during this period and persisted in carrying it through to publication thanks to the encouragement and support of some of the psychiatrists and psychologists I met through NAMI. After I had written the first complete draft, I began doing some research about the phenomenon of voice hearing. (I’d been carefully instructed not to do any research or reading on hearing voices before that lest I “pollute” my story.) A few Google searches led me to the Hearing Voices Network (HVN). It must have been the Zeitgeist because within six months, the State of Connecticut’s Department of Mental Health and Addiction Services brought the HVN to Connecticut. I was trained as a support group facilitator in July 2014 and established an HVN resource group at Yale-New Haven Psychiatric Hospital, which continues. I also facilitate a weekly HVN adult support group on Zoom. I have since been trained in Intentional Peer Support, have taken a oneweek intensive course on Open Dialogue, and have just completed a five-week training for Recovery Support Specialists.

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In my early HVN days, and sometimes even now, I would say that NAMI gave me my voice—the motivation to break my silence and the training to tell my story responsibly—and that the Hearing Voices Network has set me free. My 26 years of silence were driven by fear of stigma and discrimination and the fear that because my experience appeared to be very, very unusual, I might somehow, in speaking out about my recovery experience, be providing false hope. But I’ve learned through the HVN that only 33% of voice hearers languish in the system. Of the other 67%, 33% never enter the system at all—they include people of faith of all cultures, shamans, and psychics. I fall within the middle 33%, people whose lives have been disrupted by great stress, have had a couple of hospitalizations, and who have gotten better, with love and support, and have learned to carry on with their lives.

Knowing for certain that I am not unusual, and definitely not unique, removed most of the concerns that had compelled me to keep silent, so I went back to the career path I had abandoned in the twenties, but in a different form—not as a clinician, but as peer support. I thought briefly about getting a second master’s degree so I could practice but realized I didn’t want to have to learn and regurgitate perspectives that I disagreed with. So the path of peer support seemed the most viable option.

The primary peer support work I’ve done thus far has been as a Hearing Voices Network support group facilitator and as a NAMI In Our Own Voice presenter. I have also testified before the Connecticut State Legislature several times about the factors that contributed to my largely successful recovery—mostly the privilege of having good private insurance, education, and the relative maturity and self-assurance to be able to

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choose therapists who actually listened to me.

Not everyone is as lucky as I am—well, actually, we know that 33% are not so lucky. I also speak as widely as I can—at conferences, in webinars, in various gatherings of people with lived experience, family members, and clinicians, to share the fact of my recovery and to broaden knowledge and understanding of the Hearing Voices Movement and other peer movements—and the transformative changes they have brought to innumerable people’s lives worldwide. My goal in doing this work is to help move the system toward making available to all the “luck” that I had, including good health insurance and providers who were able and willing to see me as a person and hear and believe my story.

Bien: I’d like to turn the question back to you—what drew you to the Hearing Voices Network and psychoanalysis?

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Brown: Long before I was a psychologist, I worked as a peer in the world of harm reduction, so I was always interested in that type of “lived experience” activism, coming from my own personal motivations. I also grew up in the 1990s New York punk scene, which came with this “do-it-yourself ”

ethos, as well as a pride or appreciation for people who are different. Although I’m not a voice-hearer, I’ve had comparable experiences, particularly in my youth, so I felt such a strong connection when I learned about the Hearing Voices Network.

I loved the idea that painful or unusual

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experiences aren’t the product of a deficit but are meaningful and have something important to say about a person’s life history and social context. I also loved the way the Hearing Voices Movement, similar to punk, embraced difference. When applied to “mental health,” these ideas completely

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changed the way I thought about myself, and I began to see that the things that I was hiding or ashamed of were strengths when looked at from another perspective. Some of these same ideas were also what drew me to psychoanalysis. When I was looking to become a psychologist, I loved the fact

that this whole school of thought felt that before you could become a therapist (analyst), you need to be a patient (analysand).

I also think that psychoanalysis is similarly subversive, at least certain forms of psychoanalysis, and refuses to collapse experience into an illness or singular model.

This reminds me of something I wanted to ask you. Françoise and Jean-Max have this idea that “psychosis” is connected to historical trauma. Do you feel that is the case for your experiences? I know you immigrated to the U.S. during a time of political strife in China. Do you see a connection?

Bien: Yes, I absolutely feel that my experiences of “psychosis” were related to historical and familial trauma. By the time I was born, the preceding 14 years of my parents’ marriage had been filled with refugee flight within and from China, first from the Japanese and then from the Communists. My eldest sister, Elaine, was born in Hong Kong during the Japanese occupation of China; the family returned to China in the 1940s, and my middle sister, Daphne, was born in Shanghai after the end of World War II. I was born in Hong Kong, where the family had again fled in May 1949, just weeks before Mao’s troops marched into Shanghai.

Many leaders in the HVN, who have experienced horrific, heart-breaking, mind-numbing abuse, sometimes from very early childhood, identify trauma in its various forms as the primary source for most of the voices they hear—including not only the voices that bedevil us, stirring fear and despair in our hearts, but also the voices that provide comfort and guidance and a means for continuing to wake and rise in the morning and to carry on with our days. For the first several years of affiliation with the HVN, I had a severe case of imposter syndrome. My traumas—my parents’ refugee flight, maternal distress during gestation (my mother’s distress at saying goodbye to her parents in 1951, while I was in utero), Mother’s subsequent decades-long depression because she did not know whether anyone in her family survived communism or the cultural revolution), my immigration before age four, along with some sibling rivalry, snippy friends, and toxic offices didn’t seem anywhere near serious enough to warrant the nature, depth, and degree of my most extreme experiences, especially when compared with those who have been horrifically physically and psychologically abused. But then, through Françoise Davoine, to whom I had introduced myself in 2018, I learned to begin exploring the historical and familial nature of my trauma—my parents’ immigrant and refugee status, my parents’ and eldest sister’s 27

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wartime flights from the Japanese and the Communists, and Mother’s deep depression—manifested as silence—when I was growing up.

Brown: I think this point you are making is so important, that sometimes it might seem like the peer movement emphasizes experiences of physical or sexual abuse at the neglect of other forms of trauma.

I think that is important regarding what psychoanalysis has to offer or add to the conversation; that is, a very broad view of trauma. On the other hand, many forms of psychoanalysis (other than perhaps Jungian) do not have a good understanding of spirituality, so the peer movement adds to the conversation. Do you have a spiritual lens to the way you understand your experiences?

Bien: My extreme experiences can be understood through both trauma and spiritual lenses, what I consider to be an existential crisis in addition to the workings of the collective unconscious or that which we know or believe to be God. These beliefs are consistent with the perspectives of the Hearing Voices Movement. I think it may be more accurate to note that my difficult experiences were trauma-based. The sources that helped guide me to a place of greater strength—and ultimately to and through my recovery—are spiritually based. I should explain. A part of my self-understanding has come from the guidance of minds and hearts (intellects and spirits) that did not seem ever to have been a part of my life, but that heard my calls for help when I was tormented by forces that I could not see, did not understand, and over which I was powerless—until, in answer to my prayers, those benign and sometimes actively kind presences and voices encouraged me to stand up to the monstrous and oppressively demanding presences. I should add that the form much of that guidance took was not as suggestions from beyond, but rather as an encouragement to draw upon the core of my own beliefs and the teachings of my parents, especially my father and others I have respected and loved. And that includes those wonderful humanistic psychiatrists I read in graduate school and continue to read as I re-engage with the mental health system.

Quite recently, and very slowly and sporadically, I have also begun to undertake an exploration of my neurodiversity, and the conditions—historical, familial, gestational, environmental, and ultimately psychological and social, that led to my childhood vulnerabilities and challenges, and that have paved the way for my becoming the person I am today. It is all so relative.

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It has long been said by those who know and love me, and I have long acknowledged, that I am “too sensitive.” That sensitivity is not just psychological and emotional, but also physiological, a frequently confusing and sometimes painful sensitivity to other people’s energies—born not only of demeanor, and mood, and language, along with joy, sorrow, and rage, but also desire for connection, dominance, or control. And let’s not forget the frequencies of sound, and, when strong, and especially in the wilderness, the seeming pull of the living planet and all its creatures. It is unusual, it is a vulnerability, but I maintain that it is physiology, not brain disease. It becomes disease only when not understood, or misunderstood and pathologized.

Brown: Yes, this brings to mind what I was saying about the peer movement, that it turns “vulnerabilities” into strengths, for example, thinking about how people who are physiologically vulnerable or “too sensitive” have important insights about the world. This is something psychoanalysis can bring in more, moving beyond a deficit model towards something more teleological. Françoise and Jean-Max certainly bring this in with their idea that madness attests to historical truths that have never been inscribed. In the seminars, they talk about how, from this perspective, madness is not an illness, but a strength in the fight against erasure.

Bien: This brings my next question. I’m curious also to learn from your clinical/ professional perspective on how these varying approaches, the peer/survivor movement and “more traditional” psychoanalytic perspectives, may have a particular resonance with each other? There is much opportunity for the peer movement and the psychoanalytical approaches (ISPS and other organizations) to collaborate and move the profession toward more person-centered approaches.

Brown: In terms of resonance, one writer I admire is Erin Soros; she’s a Canadian short story author and also an academic writer on madness, literature, and psychoanalysis. Her Twitter account is really fascinating and always food for thought.

She once said something on there, and I’m paraphrasing here, but it was something like, if you are looking to “build bridges” between disciplines, make sure that what you are seeking to “bridge” hasn’t already been there the whole time. She talked at the time about Black Studies and psychoanalysis, but I think this could also be said for psychoanalysis and the peer/survivor movement. Psychoanalysis has always

been a discipline formed by “people with lived experience.” This could be understood in a broader sense, for example, that Freud’s neurosis formed the basis of his theories. Still, it can also be understood in a sense much more closely connected to contemporary understandings of peer support. So-called “mad persons” were always part of psychoanalysis. Still, the aspects of their lives connected to madness have often been silenced or de-emphasized to legitimize the discipline. C.G. Jung may be the most well-known example; however, Sabina Spielrein is another great example.

Sabina Spielrein was a woman who experienced psychosis and later became a psychiatrist. Some say she wrote the first case study of a psychotherapeutic approach to psychosis. When you read her work, you can see that it comes directly from a place of lived experience. She sees psychosis as having deeply profound meanings, a type of symbolic “code” through which a person is attempting to work through something painful. Like the peer movements of today, she sees trauma, including sexual trauma, as playing an etiological role.

What a truly remarkable figure, but she hadn’t been recognized by the field of psychoanalysis in her own right until very recently by people such as Adrienne Harris.

Bien: Yes, I agree. I like Erin Soros’ observation that the bridges we seek to build may already be there. I do sincerely believe they are—and have been—but they have fallen into such disrepair.

Brown: And then there are also a lot of conceptual similarities between psychoanalysis and peer support. Analysts such as Harold Searles discussed the importance of mutuality in psychotherapy or the idea that the “patient” is not the only one being healed; the analyst also gains therapeutic benefit. Françoise Davoine has a similar idea that the analyst often has a shared history with the patient. Some of these ideas remind me of the ideas behind, for example, Intentional Peer Support (IPS), which conceptualizes the peer relationship as a partnership in which both people benefit and grow. It’s not just about one person “helping” another.

Bien: I was trained in IPS in May 2019 and know that the peer movement warmly embraces it. The partnership aspects of Shery Mead’s IPS framework constitute the golden rule of peer support—and the peer movement would suggest that it really should constitute the golden rule of all mental health care. The four tasks of IPS, Connection, Worldview, Mutuality, and Moving Towards, seem resonant with the 28

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psychoanalytical model as practiced by many members of ISPS. By that, I mean the mutual goal of the peer support and the individual, or the analyst and analysand, to move toward a shared understanding of the nature and sources of trauma past and present, the world(s) in which one currently lives, with a view toward the future, without judgment or shame. The more recent inclusion of peer professionals in such psychotherapeutic practices as Open Dialogue also offers great hope. It will go a long way toward reinforcing existing bridges and toward building new ones.

Brown: Yes, and Open Dialogue also has roots in psychoanalysis, particularly the work of Bert Karon, so that is another interesting way that the peer movement and psychoanalysis have been brought into more conversation with each other. Of course, there are such strong divides, too, as psychoanalysis also has a very damaging, pathologizing history. Do you think these two worlds are irreconcilable? How do you think most people in the peer movement think about and understand psychoanalysis today?

Bien: I do not think the two worlds are irreconcilable. There is deep resonance among the Hearing Voices Movement members with Jung’s perspectives and all spiritual understandings for helping to stay—and to guide— our paths through life. Both the HVN and the IPS framework embrace a trauma-informed perspective, similar to psychoanalysis. I think they’re moving on similar paths. And members of the two worlds are increasingly speaking/collaborating—at conferences, in research, in publications. So there are already intersections. We just need to expand the conversations to other arenas, to other, more skeptical, worlds/disciplines. And we need not only to be creative, and mutual, and kind, but also hard-headed and practical, pointing to the economics involved in these changes and to social justice across all sectors of human endeavor. So many benefits can be derived from equitable

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investment in all humans, not just the privileged few. A number of brilliant economists support the social justice perspective that when we are all able to be our best selves, we can all thrive.

Bien: And again, I turn the question: do you think there is hope for reconciliation?

What do you think is the best path forward?

How might we begin to reinforce those existing bridges—and to find the support to build similar bridges with other, like-minded organizations, as well as bridges toward systems of power and influence?

Brown: I think that both communities need to dialogue more with each other.

Many people in the psychiatric survivor/ peer community are rightfully hesitant to embrace or even listen to psychoanalytic principles. There is a stereotype about analysts, which I think at times can be true, that they keep people at a distance with over-intellectualization that can feel so far from anyone’s actual lived experience. Likewise, I think that many psychoanalysts, especially those outside of ISPS, do not even know about the peer or survivor movement and the bridges that exist. Psychoanalysis is becoming more and more politically engaged, particularly regarding anti-oppression; for example, increasing interest in Black Lives Matter, decolonization, and feminism. However, the

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field hasn’t necessarily shown this same interest regarding sanism and the mass human rights violations inherent in our exceedingly more carceral and coercive mental health system. This intersectional issue is a notable absence from mainstream psychoanalytic discourse. So, essentially, I think it comes down to mutual education and dialogue. I think that once these two communities have a recognition of their similarities and shared motivations, they can begin to work together to influence larger systems. z REFERENCES Gaudillière, J.-M. (2020). Madness and the social link: The JeanMax Gaudillière seminars (1985–2000) (Françoise Davoine, Ed.). Abingdon-on-Thames, England: Taylor & Francis.

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Postpartum Psychosis My son was three months old when I started seeing devils in his eyes.

We were away from our home in England, on a cross-country tour of the United States visiting family and friends.

Our families were Korean, and even though they’d spent many decades in the United States and had raised us as Americans, the rules and superstitions around birth were deeply engrained. They thought we were being reckless, traveling abroad when we should have been shielding ourselves at home, hiding away until our baby had reached the “safe” age of 100 days.

Their warnings and comments, although kindly meant, were constant. “Don’t hold him too tightly, you might drop him.”

“Put more layers on him, he might catch cold and die.” “Wash your hands, he might get the flu and die.” I started to see danger everywhere, and I wondered if I was a danger to my son.

My descent into psychosis was sudden and unexpected. Within hours, I was seeing devils’ faces in the strangers at the grocery store. I was hearing the voice of God through the curtains, telling me that my husband was Dante, that I was Beatrice, and that we were destined to walk through

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the circles of hell. It felt like the world was being shaken, the colors were too vibrant, everything felt exaggerated.

My husband would take me to the emergency room. By then, I was tearing my clothes, clawing and fighting with the nurses who wrestled me onto a gurney.

When I was admitted, I couldn’t be sure of what was real and not real.

My mind would build false memories, weaving stories from my past with books I’d read, films I’d seen, or song lyrics I remembered. I have distinct memories of my husband holding my hand, just as I have memories of him trying to serve

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me human flesh, of him being tortured by nameless demons.

I remember seeing faces at the window of the observation room—faces of demons, of ex-boyfriends, of my son. I stayed in the hospital observation room for four days, and even though the doctors gave me medication, I did not sleep.

In psychosis, it was as though the bridge between reality and imagination was broken. My mind was exposed—raw and pulsing. Time was no longer linear; I was experiencing each moment continually, again and again with slight variations.

I remember terror. I was afraid of my fate, of being alive for eternity only to be tortured. I kept trying to wake up, to believe this was a nightmare, but I couldn’t wake up. I believed desperately that I needed to end things, to exit. I looked for an open window, I wondered if I could jump off a balcony. The only thing that held me back was my refusal of leaving my husband behind.

I didn’t want him to remain in the loop of hell forever. I kept trying to tell him we needed to exit, but he didn’t seem to listen, no matter how frantic I was. After four days, it was decided that I would be admitted to a psychiatric ward for treatment.

Within the moments of terror, I also remember the kindnesses of the people around me. There was a nurse who spoke to me gently, who told me not to be afraid, and another nurse who braided my hair, smoothing out the tangles. One of the security guards held my hand in the ambulance on the way to the psychiatric facility and only nodded while I told him about the end of the world.

At the psychiatric ward, I would experience a complete mental break. I became agitated; the workers were rough, impatient, and I could sense their fear.

I thought I was surrounded by wild animals. I remember screaming and fighting. I stripped off my clothes and urinated on the floor—a way to show the animals that I was just like them. My husband tried to help, but they pushed him out of the room.

I was sedated, and for the first time in four days, I slept.

When I woke up, I felt unmoored. I wasn’t sure what had been real, I wasn’t sure of who I was. I would spend the next days trying to put myself back together, to trace what had happened.

I had a notebook that my husband had left for me. I was wearing his clothing, his sweaters. I spent my time shuffling up and down the hallway, trying to feel a sense of purpose, to feel time passing in a place where it didn’t feel like time existed at all.

I went to group sessions, I took my medication. I fit into the pattern of the ward, where so many things were unspoken. No one ever told me where I was or what the rules were or when I would get to leave. It was as though I’d just appeared in that place, and I sensed that in order to get out, I would just have to go along with the rules.

I did not think of my son when I was in the ward. I had the physical reminder that I was a mother. My breasts were knotted, a network of angry red lines from not breastfeeding. I would express milk into the sink every few hours. When I did try to think of him, I felt a dull blankness. I couldn’t remember his face. Sometimes I would look at the photographs my husband had left for me, and remind myself that the baby in those photographs was my own.

By the time I was released, I had spent a total of 12 days away from my son, but the severance was complete. I had no emotion towards him, to hold him was physically painful, and I could feel my body fight against it. When I had the chance to think about it more, I would believe that it was an act of biological survival, a way to protect him from a mother who couldn’t be trusted.

We would return home, and I would spend my time trying to recover. The antipsychotic medication made my hands shake, I had difficulty sitting still, and my eyesight was blurred. My husband would tell me that I was still speaking nonsensically at times, and he started to sleep in the hallway because I would sleepwalk and talk about wrapping our son in plastic.

A few weeks after my release, I would fall into a deep depression. To me, it was a complete surprise, although my husband and my psychiatrist told me that it was to be expected. The depression was immediate, a darkness that was so complete that there was no hint of light that remained or even the memory of it.

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My psychiatrist suggested that I be admitted to a mother-baby unit, but my husband decided against it, believing that it would be too difficult for me to cope with spending time with our son in a facility. Instead, I spent my time at home in bed, trying desperately to come back to the surface, willing my body to move, to sit up.

It was during these months that I decided that I wanted to write about my experience. Any moment when I felt a sense of clarity, I would write down a few sentences in my journal, trying to capture that feeling, and trying not to feel despair when the darkness returned.

I couldn’t imagine that this feeling of darkness would pass, but I had to believe that it would. And eventually, after several months, it did pass. I was able to go through the motions of “normal” life—I went back to work, I went to the parent meetings at my son’s nursery, I took notes during his medical check-ups. I smiled when people asked about my maternity leave, and I nodded when asked if I missed my son, even though I still felt separate from him.

Understanding that I was a mother was the last part of my recovery. I had learned to overcome the pain I felt when I was around my son. I could hold him for longer periods of time, but I still felt distant from him. I had to remind myself to smile at him, and for a long time, he would look at me blankly without any expression, and I realized he was mirroring the way I looked at him.

I reminded myself to reach for him, to hold him. I knew that I couldn’t recreate the bond we’d had before, that it had been lost. Instead, I made motherhood an intention, a daily routine. I thought that if I practiced enough, then one day, the word would fit me again.

And it did happen. It took time, but one day I realized that I was reaching for my son without having to remind myself.

That there was no distance when I looked at him, and I could look at his eyes without any memory of the darkness that had been there.

Sometimes I wonder if my experience with psychosis has marked me. When I try to explain how it felt, to suddenly be removed from time, I feel like I had a glimpse of something beyond the everyday, an unfolding of dimensions that had before been hidden from view. I remember the terror, I remember the darkness, but then I also remember the sharp pull of the things that kept me back, and I think instead of my son, of the memory of his hand in mine, the wish that I would one day feel like a mother again. z

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An Archive of Adjustments: Reflections of the Remnants of a Discarded Diagnosis Michael N. HEALEY

The text is crammed into the center of the card, as if to escape the fraying edges. “Main facts: Patient is a 28-yr-old single male who for the past 2 yrs has shown gradual deterioration in his performance level, with fear at first vague & of an anxiety nature, later projected as audible threats of bodily harm at the hands of his work environment.” In 1930, this troubled man, who we will call David Nolan, was admitted to the Phipps Psychiatric Clinic at Johns

United States. “We see chaotic and fantastic behavior, strained tension and disorganization of the personality,” he later explained.

“The capacity to draw ergasic resources into focus through habit and planning is completely lost” (Meyer, 1957, p.122). That awkward term, “ergasic,” was drawn from the Greek word ergon, meaning work. An ergasia, then, was an integrated function describing not only the behavior of the body, but also the mentation of the mind.

In time, however, some psychiatrists— many of an analytic persuasion—started questioning this “German dogma” and the thick line it drew between health and disease (Meyer, 1917/1951, p.51). As they sought to dissociate their profession from the asylum, and the insanity they treated there, these reformers created new concepts that linked frank pathology to normal behavior, developing what the historian Elizabeth Lunbeck has referred to as

Hopkins Hospital. For years, he had been shifting from job to job, constantly worrying that his “fellow workers were plotting against him.” In the clinic, David’s condition remained “essentially unchanged,” as he “clung to the reality of his persecutory ideas,” and insisted that others were “using malign power that interfered with his working efficiency.” Slowly, however, he became more “cooperative” and “active,” and began “restlessly demanding that something be done for him right away so that he could return to his work.” Eventually, David’s psychiatrist decided to parole him to his father, so he could be cared for by family as he tended to their farm (Case 8, keysorter card, AMC XV/500659). Although he was discharged shortly thereafter, David’s case later became part of a cohort study conducted by two staff members at Phipps: a research assistant named Gladys Terry and a junior psychiatrist named Thomas Rennie.

This is why I found his case history, along with dozens of others, on a tattered yellow punch card stowed away in the archive.

Toward the top of David’s card is an unfamiliar diagnosis, typed in fading red ink: “Parergastic Reaction.” This obscure illness, I soon learned, was first described in the 1920s by Adolf Meyer, the director of the Phipps Clinic and one of the earliest proponents of dynamic psychiatry in the

By adding prefixes like “para-” (or “dys-” or “an-”), Meyer sought to portray psychiatric disorders as deviations from normality, brought about by maladaptive responses to environmental stimuli (Lamb, 2014). “Reactions in settings and life patterns which blend their immediate experience with memories and anticipations in a common medium of meaning functions or symbolization are very often significant facts,” he explained (rather cumbersomely) in 1931, the year after David was admitted to Phipps. “For this all-important fact, the full and striking significance of which had not been grasped,” he wrote, “I needed a convenient term” (Meyer, 1957, p.48). Needless to say, it never caught on.

Most of Meyer’s contemporaries, in fact, considered the term “dementia praecox” to be far more useful. This category of psychosis, d “Because of their incapacity for regular work,” wrote Kraepelin (1896/1987), “such mentally crippled youngsters often join the ranks of beggars and vagrants, perhaps later to be admitted to the work-house or asylum” (p.16).

And indeed, once this descriptive nosology crossed the Atlantic, and overzealous Kraepelinians began using it to sift through their patients, hospitals across the United States quickly became overwhelmed with cases of dementia praecox (Noll, 2011).

the “psychiatry of everyday life” (Lunbeck, 1994, pp.46-77). For instance, August Hoch, an early promoter of psychoanalysis, began characterizing the “shut-in personalities” that were associated with dementia praecox, helping mental hygienists to detect susceptible children at their homes and schools (Hoch, 1908). Harry Stack Sullivan, for his part, later described the psychoses as “parataxic distortions” that were shaped by interpersonal relationships and thus amenable to psychotherapy (Sullivan, 1954, pp.25-27). It was Eugen Bleuler’s theory of “schizophrenia,” however, that would ultimately replace Kraepelin’s concept (Bleuler, 1911/1987).

Inspired, in part, by research conducted

by Carl Jung and others, the term became fixed into psychiatric nomenclature by the late 1920s, while the other neologisms—including Meyer’s—faded from memory.

What, then, might we learn from the remnants of a discarded diagnosis? I’d like to suggest that by revisiting parergasia, and the research that produced it, we can examine how Meyer, or rather his staff, constructed the normal upon which this “discipline of the everyday” depended (Lunbeck, 1994, p.23). He, like Freud, sought to blur that line between normality and pathology, though his etiology focused less on inner psychosexual conflicts, and more on the

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“maladjustments” that arose in various social situations (Lamb, 2014, pp.205-245).

“I persistently urged an appraisal of our experience with the many varieties of normal life, and in this setting of the normal, also the sweeping mental disorders and the minor psychoses, not only the sex-centered ones,” Meyer (1957) explained (p.49). And yet, his view of this normal was incomplete and opaque, mediated as it was by the histories obtained by his staff and, only later, by the letters they solicited from discharged patients and their families. It was these correspondences, these brief glimpses into the lives of the recovered, that allowed Terry and Rennie to assess the outcomes of their cases and to discredit the prognostic assumptions embedded in Kraepelin’s nosology. We shall see, however, that as adjustments are archived, and observations of the normal are filtered through people and paper, much can be lost or distorted.

RECORDING REACTIONS Manufactured by the McBee Company in Manhattan, Terry and Rennie’s punch cards, or “keysorters,” had been designed to facilitate the organization and analysis of coded data. Similar cards, for example, had been developed to assemble large bibliographies, so that researchers could sort references by author, date of publication, and topic. Others had been used to code collections of questions by content or level of difficulty, allowing educators to create standardized exams. Regardless of their ultimate purpose, however, all keysorting systems shared several functional characteristics. Each card would contain sections along the edges where categorical variables could be underlined, surrounded by blank spaces where qualitative data could be recorded.

Holes corresponding to each variable were punched along the edges and were either notched away or left intact to code the data.

Instead of sorting the cards by hand, then, rods could be placed through the deck to select for entries that shared particular traits (Wells, 1956). In Terry and Rennie’s system, for instance, patients like David could be selected by sorting the cards by marital status, then sex, and finally age, until all single males between twenty and thirty were identified.

Of particular interest to Terry and Rennie, however, was the section related to “adjustive capacity,” placed on the back of the card. It was here that various “difficulties” or “maladaptations” were coded according to the environments in which they occurred.

In David’s case, for instance, the “job changes” and “falling off in work efficiency” that prompted his admission to Phipps were recorded under “work maladjustment,” while the “projection of persecutory fears & influences at hands of fellow workers” was in-

cluded under “situational maladjustment.”

For added emphasis, these two entries were asterisked twice, unlike his “emancipation difficulty,” his “maladjustment” to school and sexual relationships, and his “social maladaptation,” which were simply underlined (Case 8, keysorter card, AMC XV/500659). In this way, Terry was able to sort her patients according to the situations in which they were most severely maladjusted and identify whatever functional deficits they had in common.

Each aspect of adjustive capacity could then be related to variables on other sections of the card, including those related to outcome. Notice how each patient was not simply described as “improved” or “unimproved.” Instead, like adjustive capacity, the outcome of each case was qualified, first and foremost, by the environment in which the patient was located. That is, each patient was coded as “hospitalized” or “outside hospital” before their level of adjustment in each setting was specified. David, for instance, had been coded as both “hospitalized” and “outside hospital,” with comments in the blank spaces clarifying his trajectory through the psychiatric system: “Doing very well working on fa’s farm since [being paroled one year before his permanent discharge].” In his case, as in others, the level of adjustment achieved outside of the hospital was further coded based on various social factors. That is, discharged patients could be described as adjusted to “protective life situations” (e.g., in homes with supportive families) and/ or recovered with “renewed responsibilities and activities” (e.g., by working and participating in interpersonal and communal relationships). The functional status of each patient was then elucidated with qualitative descriptions typed into margins. For example, David’s keysorter explained that he was in a protective life situation, with renewed (but “simple”) responsibilities: “living uneventful & solitary life” (Case 8, keysorter card, AMC XV/500659). Recall that on the back of the card, David’s deficits in adjustive capacity had been primarily characterized by difficulties at work. Likewise, the outcome of his case was defined, in part, by his ability to engage in productive labor.

FOLLOWING UP This sort of longitudinal observation was central to Meyer’s “ergasiology.” To supplant Kraepelin’s concept of dementia praecox, and the grim prognosis embedded therein, he and his staff had to observe their patients outside of the hospital so the factors that contributed to recovery could be isolated. “We are seeking the limits and dynamics of the balance of modifiability and plasticity,” Meyer (1957) explained. “What facts seem to dominate the present picture as factors, and what can we predict as the 33

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outcome? What are the possibilities not only of directly correcting the abnormal trends but also of raising the whole level of response?” (p.116). To answer these questions, Terry and Rennie had to collaborate with family members and social workers to monitor the adjustive capacity of patients that had been discharged into the community. For example, several years after David’s stay at the clinic, Terry wrote to his father to solicit follow-up data. “My dear Mr. Nolan,” she wrote. “Would you be good enough to write me concerning the condition of your son, David, since he left this clinic?” David’s case, she explained, was an “especially interesting one,” and it was crucial that they obtain an accurate assessment of its outcome.

“It is very helpful to our understanding and treatment of other cases to know what the subsequent developments in the case of our former patients have been,” she explained.

“Any information that you give me will be greatly appreciated.” A response arrived about a week later. “I can’t say he is any better,” Mr. Nolan lamented. His son refused to live at home, he explained, and had rented “a shack” about two miles down the road. He did visit frequently to help on the farm but spent much of his time arguing with his father. “He is a good worker & knows how to do most anything,” Mr. Nolan admitted, “but don’t [sic] seem to want to work.” Despite Mr. Nolan’s complaints, Terry considered David’s independence and self-sufficiency as signs of improvement. “We are glad to hear that with your helpful understanding he has been able to carry on outside the hospital,” she replied, dismissing his concerns. “We would appreciate it if you would keep us informed from time to time of his progress” (Case 8, follow-up data, AMC XV/500659).

Mr. Nolan never reported back, leaving Terry and Rennie with only one evaluation of David’s outcome. This was far from unusual, however. In most cases, in fact, their follow-up observations consisted of a few letters from relatives, or an interview conducted by a social worker. And yet, the quantity (or quality) of the data could not be discerned from the cards themselves. All that remained was Terry and Rennie’s final assessment, translated into the logic of the keysorters. In David’s case, for instance, their initial impression can be found on the top of Mr. Nolan’s letter: “Slightly improved - better by living alone in a shack” (Case 8, follow-up data, AMC XV/500659). Details from the letter were then typed onto the blank spaces of the card, allowing his case to be classified accordingly.

By distilling this short correspondence into even shorter statements, and coding them into Meyer’s database, Terry and Rennie were able to use this limited information to categorize David’s outcome and compare it to those of other cases.

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PUBLISHING PRODUCTIVITY As they solicited this information from patients and their families, Terry and Rennie were not simply extending the psychiatric gaze beyond the clinic. They were also establishing the parameters of recovery itself, granting Meyer the authority to

determine which traits patients needed to remain in the community. In 1938, Terry and Rennie published a book on parergasia, which analyzed David’s case alongside seventy-six others. In a table presenting the status of discharged patients, the two outcomes recorded on the keysorters were

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converted into four levels of recovery: (i) “Floated by simple, protective environmental regime;” (ii) “Floating in solitude removed from family and other social obligations;” (iii) “Renewal of responsibilities and activities at lower level or under conditions removing previous strain;” and (iv) “Re-

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covery to previous productive level.” Note that the first two levels refer to the degree of protection afforded by the environment.

The third level, too, refers to the removal of “previous strains,” but also emphasizes the “renewed responsibilities and activities” that had been categorized under option “b”

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on the card. Recovery, then, is attributed to the adjustive capacity of each patient, highlighting their ability to reintegrate into the community (albeit with various accommodations). This focus on factors intrinsic to the patients themselves is maintained in the fourth level, where cases of “recovery to previous productive level” are recorded. Indeed, when describing patients in this final category, Terry and Rennie make little mention of the environment, as patients are assumed to have returned to circumstances that were analogous to those they had left.

Instead, attention is given solely to the components of adjustive capacity that yielded the most desirable outcome: namely, the ability to remain productive outside of protective environments (Terry & Rennie, 1938, pp.122-129).

By using keysorters to arrange cases according to adjustive capacity and outcome, and by constructing a table that outlined ordinal levels of recovery, Terry and Rennie had developed a new series of observations, one which promoted a particular definition of mental health. This becomes apparent in David’s case, especially when the summaries in Terry and Rennie’s monograph are compared to Mr. Nolan’s initial assessment. Recall that in his letter to Terry, Mr. Nolan had emphasized his son’s withdrawal from, and hostility toward, him and the rest of the family. “Sometimes I can get him to help me but I always have to pay him,” he wrote. “He is good natured but very fond of argument and will always take the oposite [sic] view of things” (Case 8, follow-up data, AMC XV/500659). In their monograph, however, Terry and Rennie portray David’s social isolation as an asset, suggesting that he leads a “contented, idle and solitary life in a rented shack near home.” They include him in the second

column of the table described above, alongside other patients that were “removed from family and other social obligations” (Terry & Rennie, 1938, p.123). Later, when comparing David to other patients with “paranoid suspicions,” they cite his “return to simple farm work” as evidence that goals and pursuits “within keeping of capacity and practical opportunity” (i.e., manual labor) facilitate recovery (Terry & Rennie, 1938, p.142, 148). Yet again, his estrangement from his family is dismissed as mere “friction at home,” the relief of which contributed to his improvement. We see, then, that the details extracted from Mr. Nolan’s letter were chosen because they suggested not only that David could recover, but that he could do so solely by “doing good work” (Terry & Rennie, 1938, p.148). This, in effect, conflated recovery with the ability to engage in productive labor, while adjustments to other aspects of social life were all but ignored.

Other cases, too, were distorted by the table, as data unrelated to productivity struggled to pass from card to monograph.

For example, “an 18-year-old single Jewish man,” who had experienced “attacks of abdominal distress and fear,” was placed in the third column for “working regularly,” even though he was “glum-looking and self-concerned” and could participate in “no other activities.” And “a 34-year-old married housewife of eighth grade education,” who had “heard God’s voice saying she was going to die of cancer,” rose to the fourth, but only once she resumed “household responsibilities and activities with good adjustment” (Terry & Rennie, 1938, p.128-129).

In these cases, as in David’s, the table had reoriented the data from the cards around the notion of productivity. Patients were ranked, then, based on the labor they performed outside the hospital, as parergasia became an ailment of the unemployable.

RECOVERY AFTER THE NEO-KRAEPELINIAN TURN Though terms like dementia praecox and parergasia have fallen into disuse, this tension between descriptive nosology and dynamic psychiatry remains. Since the rise of neo-Kraepelinianism in the late twentieth century, more and more rigid diagnoses have found their way into the DSM, as psychiatric nosology has embedded itself into the larger bureaucracies of healthcare and welfare (Decker, 2013). This renewed emphasis on diagnosis and prognosis has drawn much criticism not only from the providers of mental healthcare, but also from its “consumers” (or, as some prefer, “survivors”).

Emboldened by longitudinal studies (e.g., Strauss & Carpenter, 1972) and first-person narratives (e.g., Deegan, 1988) that

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challenged the chronicity associated with schizophrenia and other severe mental illnesses, this movement has accused psychiatric services of instilling hopelessness and dependency in patients and has advocated for the adoption of “recovery-oriented practices” instead (Jacobsen, 2004). By eschewing diagnostic labels and promoting optimism and self-sufficiency, such programs aim to empower their clients, leaving them to decide what it means to recover. “For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability,” wrote President George W. Bush’s New Freedom Commission in their 2003 report, which brought national attention to recovery-oriented practices. “For others, recovery implies the reduction or complete remission of symptoms” (New Freedom Commission on Mental Health, 2003, p.5).

This brief history of parergasia reminds us, however, that outcomes are defined less by providers and consumers themselves, and more by institutional procedures and cultural values. Although current conceptualizations of recovery typically emphasize the importance of connectedness, vocational rehabilitation remains an integral component of mental healthcare, with the restoration of financial independence seen as prerequisite to the development of interpersonal relationships. Indeed, as the historian Joel Braslow and others have argued, the recovery model has been co-opted by the mechanisms of neoliberal governance, as it promotes the “flow” of consumers out of welfare programs and shifts the responsibility for mental healthcare from the collective to the individual (Braslow, 2013; Padwa et al., 2016; Morrow, 2013). We should not be surprised, then, to find that “service-defined” metrics of outcome (that is, those set by administrative and budgetary priorities) often take precedence over “clinical” or “personal” ones, inscribed as they are on the very paper (or, increasingly, electronic) records which facilitate psychiatric services (Le Boutillier et al., 2015). Those who aim to promote recovery, either for themselves or for their clients, would do well to recognize that adjustments need to be archived with intention and care.

Otherwise, definitions of mental health can be just as pernicious as the diagnoses they are meant to oppose. z The author would like to acknowledge: the Alan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions, for access to archival materials and permission to use the images mentioned above; the Privacy Board of the Johns Hopkins Medical Institutions, for permission to access protected health information; and the Hugh Hawkins Research Fellowship for the Study of Hopkins History, for financial support.

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REFERENCES Bleuler, E. (1987). The prognosis of dementia praecox: The group of schizophrenias. In John Cutting & Michael Shepherd (Eds. & Trans.), The clinical roots of the schizophrenia concept: Translations of seminal European contributions on schizophrenia (pp.59-74). Cambridge, England: Cambridge University Press. (Original work published 1911) Braslow, J. T. (2013). The manufacture of recovery.

Annual Review of Clinical Psychology 9, 781-809.

Decker, H. S. (2013). The making of DSM-III: A diagnostic manual’s conquest of American psychiatry. Oxford, England: Oxford University Press.

Deegan, P. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal 11(4), 11-19.

Hoch, A. (1908). The psychogenesis in dementia praecox. Medical Record 73, 452-454.

Jacobsen, N. (2004). In recovery: The making of mental health policy. Nashville, TN: Vanderbilt University Press.

Kraepelin, E. (1987). Dementia praecox. In John Cutting & Michael Shepherd (Eds. & Trans.), The clinical roots of the schizophrenia concept: Translations of seminal European contributions on schizophrenia (pp.13-24). Cambridge, England: Cambridge University Press. (Original work published 1896)

Lamb, S. D. (2014). Pathologist of the mind: Adolf Meyer and the origins of American psychiatry. Baltimore, MD: Johns Hopkins University Press.

Le Boutillier, C., Chevalier, A., Lawrence, V., Leamy, M., Bird, V. J., Macpherson, R., Williams, J., & Slade, M. (2015). Staff understanding of recovery-orientated mental health practice: A systematic review and narrative synthesis. Implementation Science 10, 87.

Lunbeck, E. (1994). The psychiatric persuasion: Knowledge, gender, and power in modern America. Princeton, NJ: Princeton University Press.

Meyer, A. (1951). The aims and means of psychiatric diagnosis. In Eunice E. Winters (Ed.), The collected papers of Adolf Meyer (Vol. 3). Baltimore, MD: The Johns Hopkins Press. (Original work published 1917) Meyer, A. (1957). Psychobiology: A science of man (Eunice E. Winters & Anna Mae Bowers, Eds.). Springfield, IL: Thomas Books.

Morrow, M. (2013). Recovery: Progressive paradigm or neoliberal smokescreen? In Brenda A. LeFrançois, Robert Menzies, & Geoffrey Reaume (Eds.), Mad matters: A critical reader in Canadian mad studies (pp.323-333). Toronto, Canada: Canadian Scholars’ Press.

New Freedom Commission on Mental Health (2003).

Achieving the promise: Transforming mental health care in

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America: Final report. DHHS Publication SMA-03-3832.

Rockville, MD: Department of Health and Human Services.

Noll, R. (2011). American madness: The rise and fall of dementia praecox. Cambridge, MA: Harvard University Press.

Padwa, H., Meldrum, M., Friedman, J. R., & Braslow, J. T. (2016). A mental health system in recovery: The era of deinstitutionalisation in California. In Despo Kritsotaki, Vicky Long, & Matthew Smith (Eds.), Deinstitutionalisation and after: Post-war psychiatry in the western world (pp.241265). London, England: Palgrave Macmillan.

Strauss, J., and Carpenter, W. (1972). Prediction of outcome in schizophrenia. I: Characteristics of outcome.

Archives of General Psychiatry 27, 739-746.

Sullivan, H. S. (1954). The psychiatric interview (Helen Swick Perry & Mary Ladd Gawel, Eds.). New York, NY: W. W. Norton.

Terry, G. C., & Rennie, T. A. C. (1938). Analysis of parergasia. Nervous and Mental Disease Monographs, 64, 199.

Wells, W. D. (1956). The use of McBee keysort in content analysis. American Psychologist 11(1), 53.

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NON-PROFIT ORG. U.S. POSTAGE PAID Washington, D.C. Permit No. 6348

American Psychological Assoc.

750 First Street, NE Washington D.C. 20002-4242 Forwarding Services Requested

NOTES ON CONTRIBUTORS

Claire Bien, is the author of Hearing Voices, Living Fully: Living with the Voices in My Head, and a Research Associate at the Yale University Program for Recovery and Community Health. She is on the Board of Directors, and President, for the International Society for the Psychological and Social Approaches to Psychosis United States Chapter (ISPS-US), and highly involved in the peer support movement, including the Hearing Voices Network (HVN).

Michael Healey, received his BA in biology and public health from the University of Rochester in 2016 as part of their early medical scholars program. After matriculating into medical school, he became increasingly interested in the medical humanities, and took leave to study the history of psychiatry at Johns Hopkins University. After completing his PhD, Michael plans to finish his undergraduate medical education at Rochester and pursue a career in psychiatry.

Marie Brown, is a clinical psychologist, Special Adjunct Clinical Supervisor at Long Island University Brooklyn, and co-editor (with Robin S. Brown) of the book Emancipatory Perspectives on Madness: Psychological, Social and Spiritual Perspectives.

She is on the Board of Directors, and Vice President, for the International Society for the Psychological and Social Approaches to Psychosis United States Chapter (ISPSUS), and highly involved in the peer support movement, including the Hearing Voices Network (HVN).

Brett Kahr, has worked in the mental health profession for over forty years. He is Senior Fellow at the Tavistock Institute of Medical Psychology in London and Visiting Professor of Psychoanalysis and Mental Health in the Regent’s School of Psychotherapy and Psychology at Regent’s University London, as well as Consultant Psychotherapist to The Balint Consultancy. He is also a Fellow of Freud Museum London and a Consultant in Psychology to The Bowlby Centre, and, additionally, the Chair of the Scholars Committee of the British Psychoanalytic Council. Kahr has authored fifteen books and has served as series editor for more than seventy further titles. His most recent solo-authored books include Bombs in the Consulting Room: Surviving Psychological Shrapnel and Dangerous Lunatics: Trauma, Criminality, and Forensic Psychotherapy. His next book, entitled Freud’s Pandemics: Surviving Global War, Spanish Flu, and the Nazis, will be published in late 2021. Kahr has recently become Editor-in-Chief of Karnac Books of London.

Marilyn Charles, is a practicing psychoanalyst and staff psychologist at the Austen Riggs Center. She has published over 90 articles and book chapters, and five books.

Catherine Cho, is a literary agent and the author of Inferno: A Memoir of Motherhood and Madness. She lives in London with her family.

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Danielle Knafo, PhD and Michael Selzer, MD have been treating patients diagnosed with psychosis for many decades. Danielle is a professor at LIU’s clinical psychology doctoral program where she chairs a concentration on serious mental illness. Michael directed the Schizophrenia Division, a longterm treatment facility for chronic psychosis.

Both have written and lectured extensively on the treatment of psychosis.

Victoria Malkin, PhD, LP is a psychoanalyst in private practice in New York City.

She is on the faculty of the William Alanson White Institute and National Psychological Association for Psychoanalysis. She has a PhD in Anthropology for University College, London and also teaches as an adjunct professor at the New School for Public Engagement.

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