Unbearable Affect: A Guide to the Psychotherapy of Psychosis

231 Pages·2009·1.12 MB·English

by  David A. S. Garfield

UNBEARABLE AFFECT
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UNBEARABLE AFFECT
A Guide to the Psychotherapy
of Psychosis
Second Edition
David A.S. Garfield
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CONTENTS
PREFACE TO SECOND EDITION vii
ACKNOWLEDGEMENTS xiii
SECTION I: AFFECT DIAGNOSIS 1
CHAPTER ONE
Introduction: The focal point 3
CHAPTER TWO
Forms of introduction: The chief complaint 15
CHAPTER THREE
Psychotic themes in the precipitating event 31
CHAPTER FOUR
Affect and primary process in psychosis 45
CHAPTER FIVE
Vitality affects and the self in psychosis 59
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vi CONTENTS
SECTION II: AFFECT THERAPEUTICS 75
CHAPTER SIX
Countertransference: The transmission of affect 77
CHAPTER SEVEN
The forms and transformations of affect 95
CHAPTER EIGHT
Shame, pride, and paranoid psychoses 111
CHAPETR NINE
Emotion and self-esteem in psychosis 131
CHAPTER TEN
Bearing unbearable affect 147
SECTION III: A LIFE’S WORK: STAYING OUT
OF PSYCHOSIS 163
CHAPTER ELEVEN
Putting emotion in perspective 165
CHAPTER TWELEVE
Staying out of psychosis 183
REFERENCES 199
INDEX 209
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PREFACE TO SECOND EDITION
Over twelve years have gone by since the publication of the first
edition of “Unbearable Affect” and it is heartening to see the worlds
of psychiatry, neurology, psychology and psychoanalysis embrace the
primacy of affect in human mental life (Abend and Nersessian, 1989;
Spezzano, 1993; Kantrowitz, 1997; Lane and Nadel, 2000; Damasio
2000; Diener et al, 2007). When affect is used as a guide to psycho-
therapeutic work with patients in psychosis, the ordinary can emerge
out of the extraordinary. Amidst the bizarre, seemingly alien, and
often unintelligible communications of psychotic patients, the natural
human element of emotion provides the means to guide both doctor
and patient to safer waters. By seeking out, harnessing, and rechan-
neling affect, the storms of psychosis can be successfully navigated.
Affect is the most fundamental element and background field of the
mind and brain of humankind. Like the physical elements of gravity,
wind, and lightning, emotion has force and direction. As the great
19th-century Swiss psychiatrist Eugene Bleuler (Jung, 1907/1976)
stated, “Thus, affectivity, much more than reflection, is the driving
force behind all our actions and omissions.” The neurobiologists
know, that the limbic system, also called the “primitive brain,” is the
home of affectivity. Psychologists, too, torn between the other basic
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viii PREFACE TO SECOND EDITION
ingredients of the psyche, such as thinking and volition, have given
the nod to the primacy of affect. Bleuler (1906) stated it clearly when
he declared, “Affectivity is the basis of life.”
What happens when emotion becomes unbearable? We see par-
allels in the natural world–gravity and wind turn beautiful waters
into hurricanes. Lightning strikes quickly destroy humans, homes
and forests alike. Little that is ordinary is left in the wake of natural
disaster. So too, in psychotic patients, delusions, hallucinations, and
incoherence are sometimes all that can be seen. The human being
inside is left ravaged and little remains intact.
We are also aware that the most basic natural elements, when in
turmoil, are not always explosive–at times they implode. The heat
from the earth’s core combined with the powerful pull of gravity
shifts the earth’s underlying mantle; massive faults crack open to
swallow up our usual existence. So too, when human events build
up and become too much to bear, emotion may implode, resulting in
the negativism, the autism, and the paralysis of psychosis.
The method in madness
To attend to affect-to find it, make it tolerable, and place it back in
its indigenous context is the goal of those who work with psychosis.
This is the map first laid down by the late Dr. Elvin Semrad, a clini-
cian teacher-scholar at Harvard’s Boston Psychopathic Hospital/
The Massachusetts Mental Health Center. Semrad stood on the
shoulders of Bleuler and Jung in his emphasis on affect as the orga-
nizing principle in psychosis. No doubt, Semrad would have agreed
completely with the words of the European psychiatrist, Godferaux
(Jung, 1907/1976):
“Below the cold and rational laws of association of ideas, there
are others which conform more to the profound needs of life. This is
the logic of feeling.” The affect approach to psychosis is a psychoan-
alytic approach. And yet, those who work with psychosis know that
any successful approach must also be psychosynthetic. Does conflict
bring about psychosis or do defects? With emotion as the guide to
healing psychotic patients, clinicians can see how internal emotional
strength makes bearing unbearable affect possible. Conversely, by
diminishing the affective intensity of conflict, the patient’s internal
condition is less twisted out of shape.
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PREFACE TO SECOND EDITION ix
Neuropsychiatry and psychopharmacology have made great
strides in the management of psychosis. Research in phenomeno-
logical neuropsychiatry has resulted in brilliant discoveries con-
cerning the neurological components of psychopathology. Research
on mirror neurons in empathy (Gallese and Goldman, 1998), the
cerebellar contributions to thought disorder (Taylor, 1991), the role
of language centres (Cleghorn et al, 1992) in hallucination, and
cortical-subcortical circuits (Cummings, 1985) in delusion, all make
the phenomena of psychosis better understood in their brain basis.
Psychopharmacology too, has made major advances in quieting
the storms of psychosis. Newer antipsychotic medications, novel
uses of anticonvulsants, and electroconvulsive therapy can rapidly
diminish psychotic symptoms.
Yet, neurobiology and psychopharmacology are like ocean sonog-
raphy and better fiberglass boats. They give precise indications of
the terrain and they provide better equipment for the hurricane-
force winds. But they do not show you a way out; they do not chart
the course!
Semrad’s map out of psychosis focuses on finding the affect in the
psychosis, bringing it into the patient’s body and, finally, putting it
into words in the context of the life history of the patient. His blue-
print is crucial but incomplete. Semrad begins with acknowledgment-
the finding of affect, locating it in the delusional, hallucinatory, or
neologistic elements of psychosis-and having the patient “own” the
affect. This is a good start. Semrad’s second step, “bearing affect” is
a complex affair. It requires more than bringing the unbearable affect
in psychosis into the patient’s body. Added into Semrad’s plan is the
idea that a special kind of relationship with the analyst is required.
The revolutionary contributions of Heinz Kohut (1971) to the under-
standing of narcissism and the coherence of the self are the missing
ingredients in this regard. Here the analyst is not only the co-pilot,
but also, at times, serves as the patient’s own missing eyes, ears, and
hands. The therapist becomes, in some respects, a living part of the
patient’s experience.
Finally, Semrad’s design calls for putting that which was unbear-
able affect into a new perspective. As affect is better tolerated in the
body, it can now be tied to the rational mind. Still, a better emotional
understanding of his or her history is not enough for the patient.
Remobilization, revitalization, and further development of the
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