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The psychotic wavelength – A psychoanalytic perspective for psychiatry

feature of the psychotic state is ... withdrawal and use of the organs of perception to construct artificial states of well being,” a flight into a self-induced narcotic state of grandiosity. De Masi states that therapy of psychotic conditions is qualitatively distinctive because of the pervasive nature of delusion and the absence of capacity for reflective symbolic thought about a repressed unconscious. The resulting transference is psychotic and delusional. He writes “the dreams of psychotic patients ... remain concrete objects; they cannot therefore be interpreted so as to uncover their latent symbolic meaning.” (p. 72). And “One of the difficulties presented by the understanding of dreams in the psychotic state is precisely the absence, in the patient, of the dreamer who understands the dream, which as a result becomes indecipherable.” De Masi is committed to a traditional psychoanalytic model of treatment including working with the transference, interpreting unconscious meaning, and reconstructing childhood experience. His transcripts are full of comments that sound like ordinary interpretations: “you are thinking that, you are telling me that, you are feeling, I think you are, you want” and the like. However, he does not explain how this differs from ordinary symbolic interpretation and how it is received by someone unable and unwilling to think. Although it is clear that many of his patients are psychologically and practically dependent on their primary families, he does not work with families. Although De Masi says he uses medications in treatment of psychosis, there is no indication of what medications his patients are receiving or what role they play in the cases he presents. Most of his examples are snapshots of brief interactions; few span more than a year or two, and none follow an entire course of treatment. There is no indication that such treatment can bring about substantial and lasting change. Indeed, most of the reports describe repeated cycles of florid delusion punctuated by periods of better function. DeMasi himself concludes that “Such work is never finished once and for all. In psychotic patients, insights do not give rise to stable transformations; often, any improvement is quickly cancelled out, and the old methods of denying and transforming psychic reality are always present” (p. 211). In the preface, De Masi states “I shall attempt to convey my ideas on the nature and analytic therapy of the psychotic state.” He certainly succeeds in challenging the serious reader to think more deeply about the meaning of psychosis and the dilemmas encountered in therapy. Whether he has succeeded in describing a qualitatively different kind of analytic treatment and demonstrating that it works will be for the reader to decide.