Treatment Challenges in Psychosis | Voices of Difference – Psychiatry and Psychoanalysis in Dialogue
With research showing that the classic psychotic symptoms of hallucination and delusion are much more prevalent in the general population than heretofore acknowledged, the ethical implications of early intervention treatments for individuals experiencing such symptoms, and at risk of developing psychosis, are rightly being debated. However, for certain individuals, delay in treatment is more reflective of characteristics of their illness – negative symptoms mostly – not coming to light.
In psychiatric practice, the current essentials of treatment – psychopharmacology and cognitive behavioural therapy – have as their aim remission from illness. And yet, there is no clear-cut definition of what constitutes remission. Symptomatic remission may not coincide with functional remission. The further implication is that the ‘failure’ to attain functional remission, manifested by social withdrawal or the non-achievement of vocational milestones etc., is simply a continuation of poor pre-morbid functioning that remains unaddressed despite treatment.
For Freud, positive symptoms, i.e. delusions, represent the attempt at recovery, a form of ‘meaning-making’, a thought solution in the face of the breakdown of sense, whose clinical avatars such as perplexity, poverty of speech and thought disorder qualify as negative symptoms. Jacques Lacan has proposed that, at the heart of subjectivity, what he calls The Real has a core of absens (absence of sense) that essentially has a different outcome for the non-psychotic. The psychotic’s struggle with The Real, at the heart of what, for psychiatry, is a pathological process is, for the psychoanalyst, the focus of treatment.
Through paper presentations and round-table discussion, this second interdisciplinary conference will address the subjective dimension at the heart of psychosis that negative symptoms and functional deficit signal. This has significant implications for treatment.
6 External CPD points The College of Psychiatrists of Ireland
08.45 – 09.15 REGISTRATION
09.20 – 09.30 OPENING REMARKS: Professor Michael Keane, UCD School of Medicine and Medical Science, Dublin
CHAIR: Tony Hughes, Psychoanalyst, member of The Irish School for Lacanian Psychoanalysis
09.30 – 10.00 Dr Cormac Gallagher, Dublin ‘Blessed are the pace-makers': Dementia, psychosis and the psychoanalytic discourse
Abstract: The new-found appreciation of the resilience and creativity of old and even dementing patients highlights the limitations of biological psychiatry in its understanding and treatment of psychosis. People with psychosis can be lead to construct a coherent discourse based on their recognition of key moments in their assumption of a subjective position. An over-dependence on statistically based methods of assessment and the automatic recourse to psychotropic medication run the risk of fostering a stifling rigidity on the part of both therapist and patient.
10.00 – 10.30 Dr Joanna Moncrieff, London Rethinking the drug treatment of psychosis
Abstract: This talk will challenge the current assumption that psychiatric drugs work by correcting an underlying ‘chemical imbalance,’ or any other brain-based abnormality. An alternative, ‘drug-centred’ model of drug action will be outlined that proposes that psychiatric drugs induce altered mental and physical states, and that these states may sometimes be ‘therapeutic’ by helping to suppress the manifestations of mental distress and disturbance. A drug-centred account of antipsychotic action will be presented that stresses the cognitive and emotional suppression produced by the drugs and how the desired and adverse effects of the drugs cannot be neatly distinguished. The impact of these effects on the symptoms of severe mental disorders will be discussed along with the practical and ethical implications of this sort of approach.
10.30 – 11.00 Dr Barry O’Donnell, Dublin Terms and conditions: ‘Psychosis’ and psychoanalytic treatment
Abstract: Psychoanalysis is a practice launched by the neurologist Sigmund Freud on the basis of the interpretation of dreams, products of every mental life which signify so madly that the normal and the pathological become indistinguishable. With the work of the psychoanalyst and psychiatrist, Jacques Lacan, psychoanalysis recognizes the human subject as a subject of language. Following a major disturbance of mental life – where cause may not yet be ascertainable – can there be a period allowed for the subject to speak and to be listened to? This requires that the practitioner in the field of the mental handle the auditing of the speech of a patient – one who is suffering a disturbance in their speaking and in the symbolization of their world. This listening requires the practitioner suspend the demand to quickly fix a diagnosis with seeming certainty. Lacan proposes another way of discerning the modes of mental pathology: “If the neurotic inhabits language, the psychotic is inhabited, possessed, by language.” Clinical listening which allows time for the subject to articulate their experience of disturbance – including the points where articulation fails – removes the need to form an opinion on the basis of unreliable outward signs. Drawing on the body of knowledge that is psychoanalysis provides a clinical basis for distinguishing psychosis as a distinct mode whereby the subject attempts to deal with what Lacan terms the Real.
11.00 – 11.30 Coffee
CHAIR : Dr Mary Cosgrave, Consultant Psychiatrist, Clinical Director of St Joseph's Intellectual Disability Service, Executive Clinical Director, North Dublin Mental Health Service
11.30 – 12.00 Dr Mary Clarke and Elizabeth Lawlor, Dublin Reflections on the Challenges of Psychosis
Abstract: Recent research does not support the pessimistic view of recovery outcomes in those receiving early intervention for psychosis. However the effectiveness of any intervention depends on the willingness of the patient to engage with intervention in a sustained manner. Engaging people with a psychotic illness can prove challenging. Understanding the role of individual appraisal may contribute to the engagement and management of the illness and lead to improved recovery.
12.00 – 12.30 Professor Bent Rosenbaum, Copenhagen How do I know that I have an "I"? Some guidelines for psychodynamic psychotherapy with persons experiencing first episode psychotic states of mind
Abstract: Psychoanalytic empirical research is concerned with in-depth investigation of the singular individual's mind in his or her relation to the other, as well as the dynamic field of the subject and the "Other". This field of trans-subjectivity, including the transference-countertransference dynamic, is an essential part of psychoanalytic research. How can we demonstrate, in ways that may convince Mental Health systems, that psychoanalytic treatments lead to results that favour psychoanalytic therapy with persons in psychotic states of mind, and thus should be offered to at least some of these patients?
12.30 – 1.30 Lunch
CHAIR: Dr John Sheehan, Senior Clinical Lecturer in Psychiatry, UCD School of Medicine and Medical Science, Consultant Psychiatrist, Department of Adult Psychiatry, Mater Misericordiae University Hospital
1.30 - 2.00 Dr Christian Fierens, Brussels How can we focus on the the Real of Lacan in the Treatment of Psychosis?
Abstract: The concept of lack in Lacanian theory leads to the Lacanian Real. How can the Real take the place of a conception of psychosis as a lack in the Symbolic (foreclosure of the Name-of-the-father)? Reality appears in connection with the possible. The Real is in connection with the impossible. The psychoanalytic discourse is the science of the Real in so far as it is touched in the meeting with the impossible. It is possible to focus on this Real in the approach to psychosis.
2.00 – 2.30 Dr Malcolm Garland and Dr James O’Connor, Dublin Rethinking psychosis in the 21st Century. Brief reflections from the front line
Abstract: Based on published research, the views of service users, as well as clinical experience, the presenters will critique the concept of schizophrenia. The main points shall be: The failure of the emergence of a biological explanation for schizophrenia; the “myth” of antipsychotics; the heterogeneity of “psychosis” in the real world; psychosis as just another form of psychological stress. Our summary view is that schizophrenia is too broad a term to be useful and that there are many patients with this diagnosis being treated with a pharmacological approach rather than a psychological one. We propose an aetiological/narrative based model of psychosis (“What happened to you?”) replace a phenomenological one (“What is wrong with you?”).
2.30 – 3.00 Dr Tom Dalzell, Dublin Psychoanalytic Treatment of Psychosis in Quebec: A Critique.
Abstract: The Canadian Groupe Interdisciplinaire Freudien de Recherche et d’Intervention Cliniques et Culturelles (GIFRIC) set up the “388” project in 1982 in the city of Quebec. Staffed by a team of psychiatrists, psychoanalysts, and clinical and social workers, this is a publicly funded centre for the psychoanalytic treatment of psychotic illnesses and has achieved considerable success. Holding that the French psychoanalyst, Jacques Lacan, provided only “preliminary remarks” in relation to the treatment of psychosis, GIFRIC has designed a treatment “after Lacan” which brings dreams to bear on delusions. This paper will attempt a critique and argue that the ‘later’ Lacan himself has much to teach us about psychosis and its treatment.
3.00 – 3.30 Dr Patricia McCarthy, Dublin Psychoanalysis - a different kind of therapeutic engagement in psychosis
Abstract: For the psychiatrist, negative symptoms are viewed as a sign of mental illness marked by a particular symbolic deficit. Symbolic deficit flags the imperative of the Real and as such is viewed in an utterly different way by the psychoanalyst. The concept of the Real is difficult to get across. This presentation attempts to do this by looking to the phenomenon in psychosis as it affects men, of pousse à la femme (the push to become/to believe oneself a woman) as a symbolic means of constructing a ‘meaning’ solution in the face of the Real. Distinctions between meaning, sense and ab-sens (absence or absence of sense) as these apply to psychosis will thereby be introduced. This may allow a reappraisal by the non-analyst, of psychoanalysis as a therapeutic engagement that differs from any other narrative approach.
3.30 – 4.00 Coffee
4.00 – 5.00 Round Table Discussion
CHAIR: Dr Brendan Kelly, Senior Lecturer in Psychiatry, UCD School of Medicine and Medical Science, Consultant Psychiatrist, Department of Adult Psychiatry, Mater Misericordiae University Hospital, Dublin
- Dr Richard Blennerhassett: Consultant Psychiatrist and Clinical Director at St John of God Hospital, Dublin. He has a keen interest in the work of Carl Jung and in the integration of psychotherapy within psychiatry
- Mary Cullen: Manager of Mounttown Neighbourhood Youth and Family Project, a HSE funded community based service for young people and their families. She is a member of The Irish School for Lacanian Psychoanalysis and The Irish Forum for Psychoanalytic Psychotherapy.
- Donat Desmond: Psychoanalyst in practice in Derry, member of The Irish School for Lacanian Psychoanalysis and The British Association for Counselling and Psychotherapy
- Dermot Hickey: Principal Social Worker, St John of God Hospital, Dublin and member of The Irish School for Lacanian Psychoanalysis
- Dr John Lyne: Senior Registrar in psychiatry, Coolock Mental Health Clinic, North Dublin Mental Health Services, Dublin
- Dr Ronan Mullaney: Clinical Lecturer in psychiatry, Trinity College Dublin, Senior Registrar in forensic psychiatry, National Forensic Mental Health Service
- Dr. Emer Rutledge: Consultant Psychiatrist, Our Lady’s Hospital, Navan
- Dr Consilia Walsh: Consultant in general adult psychiatry in St Vincent’s University Hospital, Dublin with responsibility for the management of the Day Hospital at Milltown and for the community based supported hostels and Day Centre.
Dr Cormac Gallagher is a practising psychoanalyst in Dublin, having studied and trained in Paris. He introduced Lacanian psychoanalysis to Ireland in the 1970s and established The School of Psychotherapy at St Vincent’s University Hospital. Founder of the Irish School for Lacanian Psychoanalysis, he is known throughout the world for his translations of Lacan’s seminars www.lacaninireland.com
Dr Joanna Moncrieff is a Senior Lecturer in psychiatry at University College London and a practising consultant psychiatrist. She is co-chairperson of the Critical Psychiatry Network. She is the author of numerous papers and several books which present a critical approach to psychiatric drug treatment, including the Myth of the Chemical Cure and The Bitterest Pills, both published by Palgrave.
Dr Barry O’Donnell is a practising psychoanalyst in Dublin. He is Head of the Department of Psychotherapy at Dublin Business School. A member of the Irish School for Lacanian Psychoanalysis, he teaches at the School of Psychotherapy at St Vincent’s University Hospital.
Dr Mary Clarke is a consultant psychiatrist and the clinical lead of the DETECT early intervention in psychosis service. She is a Senior Clinical Lecturer in UCD. Her early research on the impact of treatment delays in first episode psychosis underpinned the development of the DETECT service. Her current clinical and research interests include epidemiological outcome studies in psychosis, the delivery of early intervention services and the role of quality improvement in service development.
Elizabeth Lawloris the Principal Clinical Psychologist at the DETECT early intervention in psychosis service and the psychosis team at St John of God Hospital, Stillorgan. She provides CBT for psychosis in both services and has recently co-authored a systematic review of engagement in first episode psychosis.
Professor Bent Rosenbaum is a Specialist in Psychiatry, MDsci., Associate Clinical Research Professor, Faculty of Health Sciences and Adjunct Professor, Department of Psychology, University of Copenhagen. He is a training analyst of the Danish Psychoanalytic Society. President of the Danish Psychiatric Society (1998-2000), his areas of research interest include psychodynamic psychotherapy for persons with severe mental disorders, general and developmental psychopathology, trauma, suicide prevention, psychoanalysis and semiotics.
Dr Christian Fierens is a psychiatrist, a doctor of psychology and a psychoanalyst, member of the Association lacanienne internationale. He has written La logique de l’inconscient (1999), Lecture de l’Etourdit (2002, transl. Reading l’Etourdit), Comment penser la folie (2005), La relance du phallus (2009), Le discours psychanalytique (2012, transl.: The Psychoanalytic Discourse). For more than twenty years he is a commentator on the work of Freud and Lacan (see: www.lire-en-psychanalyse.be); some of his lectures have been published (Lecture de Encore, Lecture des quatre concepts fondamentaux de la psychanalyse, Lecture d’un discours qui ne serait pas du semblant).
Dr Malcolm Garland is a Consultant Psychiatrist at St Ita's Hospital Portrane, Co Dublin and Senior Lecturer in Psychiatry, Royal College of Surgeons in Ireland. He also works as a dialectical behaviour therapist
Dr James O’Connor is a psychoanalyst working publicly for many years with HSE Dublin North Mental Health Services in Kilbarrack, at St. Francis Day Hospital, Raheny, and in private practice. He is a member of the Irish School for Lacanian Psychoanalysis and is engaged in cartel research within the ambit of the School.
Dr Tom Dalzell works as a psychoanalyst in private practice and in prisons. A member of L’Association Lacanienne Internationale and the Irish School for Lacanian Psychoanalysis, he is author of Freud’s Schreber between Psychiatry and Psychoanalysis (2011). His current research is on the newly released Freud-Bleuler letters.
Dr Patricia McCarthy is a psychiatrist and a practising psychoanalyst. She is Director of the School of Psychotherapy at St Vincent’s University Hospital where she teaches and a Lecturer in the UCD School of Medicine and Medical Science. She is a member of the Irish School for Lacanian Psychoanalysis and Editor of The Letter: Irish Journal for Lacanian Psychoanalysis.