Category: Psychosis

Michael Garrett on psychotic symptoms as a rebus

Paul Rand’s popular Eye-Bee-M poster, a type of word puzzle known as a rebus that uses pictures to represent letters, was created in 1981 in support of IBM’s motto, THINK. February 9, 1981. Source: IBM 100th Anniversary Booklets. Author: Paul Rand. Logo image in the public domain.

“The hybrid blends of thought, feeling, and perception that are the subject of this book are metaphorical expressions of the psychotic person’s mental life. Psychotic symptoms are like a rebus that tells a story with words and images. The word “rebus” comes from the Latin phrase, non verbis, sed rebus, meaning, “not by words, but by things.” A familiar rebus contained in books for young children alternates a picture of a cow with the word “cow” in the narrative of the story.

“Hallucinations, delusions, and other anomalous subjective experiences that occur in psychosis are a special sort of rebus in which an image linked to words is pressed not into print on paper, but rather into the canvas of surrounding reality in what Marcus has called “thing presentations of mental life” (Marcus, 2017). Psychotic persons communicate in words, verbal metaphors, and images composed of altered perceptions of the outside world. Collages of images, words, and hybrid subjective states coalesce to form psychotic symptoms.

Rebus from Russian spiritual magazine “Rebus.” 1883. Rebus by Koni (ru:Кони). Work in the public domain of the United States.

“A psychotic symptom may be the patient’s good-faith description of an anomalous state of mind or a sort of puzzle of the heart to be solved by the patient and therapist, with an emotional code to be deciphered. In some cases, the metaphorical meaning of the psychotic symptom is easily understood. In other instances, the meaning is obscured by altered self-states, or hidden by particularly idiosyncratic symbols and the scars of many years of traumatic living. The psychotic person in effect hides psychological pain in plain sight within the metaphorical meaning of the psychotic symptoms.

“The psychodynamic interpretation of a psychotic symptom invites the patient to express the metaphorical meaning of the symptom in words, connected with painful emotions, associated with adverse life experiences, a process that brings split-off elements of mental life back into conscious awareness, where they can be processed to foster emotional growth and recovery.”

— from Garrett, M. (2019). Psychotherapy for psychosis: Integrating cognitive-behavioral and psychodynamic treatment (1st ed.). Guilford Publications.

Marcus, E. (2017). Psychosis and near psychosis: ego function, symbol structure, treatment (3rd ed.). Routledge.

Harold Searles on the pitfalls of being “the dedicated physician”

Andrea Mantegna, Christ as the Suffering Redeemer, ca. 1495-1500, Statens Museum for Kunst, Copenhagen.
Author: Richard Mortel. Licensed under CC BY 2.0.

“Unconsciously, the therapist is bent on maintaining the patient in an infantilized state, and is opposing that very individuation and maturation to which, at a conscious level, he is genuinely dedicated. I, for one, tend dedicatedly to remain immersed in a rescue-effort toward the ‘fragile’ patient, in order to avoid seeing him or her as being stronger, or potentially stronger, than myself.

“For example, one hebephrenic woman…would evidence, from time to time over the years of our work, remarkable forward surges in her ego-functioning, and unfailingly I would find that my rejoicing in this development was outweighed by an upsurge of my feeling inadequate. I had been feeling despair at how grievously ill she was; but now I would find her manifesting an appearance of blooming physical health that made me feel old and jaded, and I would be reminded, ruefully, too, that she was physically taller than I. In the same process, she would reveal a kind of effortless savoir faire, in matters both interpersonal and cultural, traceable to an upbringing far richer in social and cultural ‘advantages’ than my own.

“In short, I would feel her to be an all-around hopelessly larger person than myself. Then, as if quickly detecting that I still couldn’t take it, she would soon be, again, her deeply fragmented, ‘hopelessly ill’ hebephrenic self, and I was once more in my comfortable role of the long-suffering Christ trying to heal this wounded bird.”

* * *

“The more deeply one examines the psychodynamics of the dedicated-physician therapist who is unconsciously devoted to preserving the status quo, one finds that he holds, at an unconscious level, split images, one an idealized image and the other a diabolized image, of himself and of the patient as well, and that he is dedicated, unconsciously but tenaciously, to preserving these split images and preventing their coalescence, with the leaven of reality, into realistic images of himself and of the patient as two fellow human beings, each possessing both strengths and limitations on his strengths, each capable of hating and loving.

“I want to emphasize that it is no pernicious thing consciously to regard the patient as supremely important and meaningful to oneself. For us consciously so to relate to him can only enhance his self-esteem and help him to become whole. The pernicious thing is that we repress both our idealized image and our diabolized image of him, hide both from ourselves and at the same time act out both these toward him, by inappropriately employing, in psychotherapy and psychoanalysis, the traditional dedicated-physician-treating-his-patient approach that, however conventionally accepted in the practice of medicine generally, congeals and reinforces the wall between patient and doctor when we employ it in this field.”

— excerpted from Searles, H. F. (2017). The “dedicated physician” in the field of psychotherapy and psychoanalysis (1967/1979). In D. B. Stern & I. Hirsch (Eds.), The interpersonal perspective in psychoanalysis, 1960s–1990s (pp. 32–44). https://doi.org/10.4324/9781315471976-3