We are only just beginning to think about
our thinking on psychosis. We do not understand
the phenomenon sufficiently, let alone how
it is caused. This very discourse, which is
socially conditioned, presumes that psychosis
is some sort of determined thing, something
that is substantive and real, something medically
objectified and classified, and that it has
a biological basis or genetic etiology. But
those in clinical practice encounter different
realities than those in the research lab.
Psychosis never appears the same way. Why
would we assume it has the same underlying
mechanisms, let alone cause? Why would we
lump human beings together into a socially
constructed and contrived category? I must
admit that I am uncomfortable even referring
to a class of patients as "psychotic,"
as I feel this is disrespectful and displaces
a person's human dignity, although I understand
we are cognitively disposed toward classifying
phenomena, and as professionals we must hold
a common language for communicating shared
meaning. I suppose this label is due, in part,
to the historical aftermath of the simple
binary invented between the "neurotic"
and "psychotic" to distinguish both (1)
a form of psychic structure, and (2) a level
of severity in clinical presentation. Perhaps
this gives us more of a clue as to why we
invent these binaries to begin with. Difference
and differentiation underlie all classifications.
Mind is oriented toward differentiation, splitting,
and bifurcation; and because of this cognitive
propensity, humanity is compelled to see the
world of phenomena in such fragmented fashions.
But if things are divided, hence separated
and splintered-off from one another, does
this not speak to a primordial nature of mind
revealing itself through a simple economy?
We often hear of schizophrenia as being a
"divided self;" but don't all human
beings have a divided mind, in fact numerous
divides? How do we make value distinctions
of this sort when splitting and division are
behind the structural processes of thought?
We should never assume that the label "psychosis,"
derived from the ancient Greek ?????? (psukhosis)�which
literally means animation, or of giving life
to-applies to a mere anomalous subgroup
of psychiatric patients. It does not, for
it applies to us all. It is only in modern
times that psychosis came to signify mental
derangement. And even here, we must admit,
that we have no professional consensus on
what constitutes derangement based on the
cultural and linguistic relativity of definitions
of normativity and abnormality.
May I suggest that we do not truly understand
the mechanisms of psychosis, nor what is truly
its cause, let alone how to treat it optimally.
I suppose using brain language promulgated
by cognitive neuroscience and genetic biology
is enough to satisfy the medical profession,
and certainly the pharmaceutical industry,
but it has limited therapeutic currency and
crippling theoretical shortcomings that are
barely addressed by the multidisciplinary
field of mental health.
And any discussion of personality structure,
the attachment system, desire and defense,
developmental trauma, interpersonal matrices,
the social link, and the psychological needs
and conflicts informing mental functioning
are eclipsed for reductive explanations fixated
on the neurobiology of thought disorder. Unfortunately,
this form of medicalization of the human being
fails to adequately understand the intrapsychic
and intersubjective complexities of psychotic
states, nor does it address the real needs
of patients.
Here I wish to revisit what we mean by psychosis,
including examining its essential structure,
and argue that it forms a core in normative
human thought and mental functioning, but
with the following caveat: it manifests on
a spectrum of clinical symptomatology and
dysfunction.
The Psychotic Core
Let us begin with a few speculative queries:
Is psychosis a normative and universal feature
of the psyche? Does it have a developmental
correlate beginning in infancy that becomes
suffused in the structuralization process
inherent in personality formation? These are
not idle questions, for this would mean that
psychosis is a necessary aspect of psychic
organization. In other words, it is not merely
accidental, acquired, or contingent upon extrinsic
conditions or cultural environs, but rather
it would be psychogenically determined a priori.
Psychoanalysis has traditionally assumed that
a psychotic core lies at the heart of psychic
organization inherent in both normativity
and madness (cf. Eigen, 1993). We may historically
observe how this assumption was posited by
Freud and solidified in classical theory beginning
with the primacy of unconscious fantasy and
hallucinatory wish-fulfillment in early infancy,
only to be radically developed by the Kleinian
school in postulating an early developmental
model that places psychotic process at the
fount of psychic structure. Here the infant
is believed to be besieged by persecutory
and fearful anxieties and destructive impulses
that have been split-off, projected, and reintrojected
back into psychic structure characteristic
of paranoid-schizoid processes (Klein, 1946;
Bion, 1957). This assumption further led developmental
theorists to consider rudimentary solipsistic
and symbiotic stages, fragmentary structures,
uncohesive self-states, and autistic positions
that have a psychotic nucleus at their origin
(Mahler, Pine, & Bergman, 1975; Kernberg,
1975; Kohut, 1971; Ogden, 1989). But can this
line of thinking be sustained today? Or does
this speculative theorizing merely perpetuate
its own psychomythology?
With current findings from infant-observation
research favoring attachment theory (Beebe
& Lachmann, 2014; Cassidy & Shaver, 1999;
Fonagy, Gergely, Jurist, & Target, 2002),
the proposition of normative psychotic processes
are largely drawn into question, hence attributing
psychotic phenomenon to attachment dysfunction,
disruptions in internalization, structural
disfiguration of a cohesive self, and early
developmental trauma or abuse fueling disturbed
self-representations, faulty object choice,
and maladaptive interpersonal relationships
(Fonagy, 2001; Mills, 2005). That is, when
psychotic processes are later detected in
people, this would be correlated to the biologic-progressive
interactions produced by the attachment system
or infant-mother dyad, and would apply to
abnormal populations rather than observed
or ascribed to normal developmental sequelae.
In other words, insecure, dysfunctional, and
disorganized attachments can condition or
lead to psychosis, not that it is innate to
begin with. This conclusion further challenges
modern psychiatry and neuroscience with its
emphasis on biological, chemical, and genetic
essentialism as the culprit behind the etiology
of psychosis. Here neurobiology or genetic
determinism undergirding psychosis theory
must seriously contend with how attachment
and cultural processes affect the development
of psychotic organizations that are recalcitrant
to materially reductive and simplistic models
that prejudicially and politically drive the
education, training, and economics of psychiatry
today.
But let us return to the question of whether
there is any plausibility in proposing a psychotic
normativity that lies at the heart of psychic
organization for all people universally. Is
psychoanalysis guilty of committing a genetic
fallacy when positing a psychotic core? That
is, can the presence of any psychotic process
(e.g., disordered thoughts that defy objective
reality, ego dystonic fantasies, delusions,
hallucinations, and so forth) be traced to
earlier psychological configurations that
comprise the ontogeny of the self within a
psychosocial matrix that forms the building
blocks of psychic reality? Despite advances
in infant-observation research, the bottom
line is that we can never know what an infant
truly is thinking or experiencing internally
(Stern, 1985). Epistemologically we are exempt
from ever knowing. Here we may say that the
question becomes hopelessly moot because it
eludes direct empirical inspection, as all
we can do is infer from observation and offer
retroactive interpretations that conjecture
to explain what we think is going on inside
a baby's head within its current environment.
Whatever explanatory models we offer are ultimately
speculative, even if based on inductive and
abductive arguments, which are largely devised
to pragmatically help us deal with theoretical
conundrums and guide clinical praxis. This
is why, I argue, that any psychoanalytic model
of infantile development entails an explanans
grafted onto an epistemologically foreclosed
explanandum that is proffered to help us neutralize
our ambiguity when encountering psychological
phenomena not open to extrospection by virtue
of the fact that it may only be known through
first-person experience. From attachment researchers
focusing on representational models, affect
regulation, and mentalization functions operative
in the development of the self, to contemporary
Kleinians hypothesizing about the primitive
anxieties and fantasies that beset the infant
in the first months of life, our diverse theories
allow us to navigate the turbid waters of
uncertainty any science or humanities wishes
to mitigate.
We may reframe the question of the normative
universality of psychotic process as a logical
posit. I have argued that the mind is dialectical
from its inception, and a basic dialectical
logic of differentiation, modification, and
synthetic reintegration accompanies all psychic
development in our process of becoming (Mills,
2000a, 2002a, 2010). Here I have relied heavily
on Hegel's dialectical logic, but have offered
my own amendments and emendations based on
the observance of clinical and cultural regression,
the selective process of internalization and
retention, and the abolition of any grand
metaphysical absolutism that informs the process
of sublation (Aufhebung). Rather, mind developmentally
forges its own internal structures based on
dialectical oppositions, differences, complementarities,
and unifying principles that both expand and
elevate its internal structure, but with the
stipulation that the structural machinations
of negation and conflict ensure that individual
and collective life will always be infused
with pathos. What this means is that it is
possible for mind to slip back to previous
primitive forms pressured by fragmentary,
unmediated, irreconcilable divisions or fissures
in the psyche that are inchoate and equiprimordial,
what may not be inappropriately called psychotic
in nature regardless of a person's capacity
for healthy functioning.
The Process of Thinking and the Ontological
Divisibility of the Psyche
If psychic life is conditioned on a primal
polarity that vacillates in, between, and
through negation, opposition, and difference,
then a basic splitting or rupture lies at
the crux of mental functioning (see Mills,
2000b). In fact, we may say that splitting
lies in the very act of thinking itself, for
mind institutes division and separation in
any cognitive operation by apprehending, breaking-up,
and mediating objects. This is central to
Hegel's (1831) Logic as progressive dialectical
mediation that at once negates or annuls opposition,
while at the same time incorporates or subsumes
such opposition through the very act of elevating
itself in a new mediated dynamic. In other
words, thought generates, confronts, and vanquishes
difference as it integrates it within its
own psychic reality while transcending its
immediate experience in a higher synthetic
unity the very process of logical mediation
brings about. Sublation (Aufhebung) is Hegel's
term used to describe the dialectic that at
once cancels, preserves, and elevates opposition
within a higher developmental achievement
the mind actively constructs. This complex
process transpires in the rudimentary operations
of thinking and cognition as mind generates
various divisions and chasms via its entry
into antithesis it is compelled to shore up
and reintegrate back into its internal structure.
It is in the act of radical negation or splitting
where mind first institutes itself as thought.
Here we may see the seed of an inherent pathology:
cleaving, dividing, chopping-up objects in
thought opens us to our inherent emptiness
and incompleteness, the very nature of desire
as being-in-relation-to-lack. Mind is always
in a divide, hovering in and out, over and
through, its separations or gaps in being.
How would this process appear as psychosis?
And more specifically, how would this appear
to the psychotic? Following Hegel's lead,
psychosis would appear as the inability to
sublate or mediate objects in thought. This
would at the very least imply a failure to
adequately synthesize or unify representational
objects of self, other, and world into a rational
or meaningful structure. I further suggest
that such a failure at dialectical integration
would involve an attenuation of (or even a
possible foreclosure of) sentient-affective
mediation and the obstruction of semiotic
linkages necessary for furthering the representational
process of sublation. Put tersely, the psychotic
lives in the gap. Here there is no mediated
synthesis, no integration of imago, emotion,
and meaning, only fragmented and fragmentary
experience. In Hegel's language, the psychotic
is confined to being-in-itself rather than
being-for-itself, hence relegated to onesidedness
and schism. But as Hegel (1830a) continues
to tell us,
this stage of schism must itself be sublated
in turn, and mind must return through its
own agency to union with itself. This resulting
union is a spiritual one, and the guiding
principle of that return lies in thinking
itself. It is thinking that both inflicts
the wound and heals it again ( 24, Zusatz
3).
Here Hegel intimates how thought produces
both psychic pain and healing, which is not
only therapeutic, but spiritual. Spirit or
mind (in German, Geist) is Hegel's term
for the psyche at the zenith of its development,
which is dependent upon the dialectical progression
of the unconscious soul encased in immaturity
and early developmental conflict. Following
Hegel's logic of the dialectic, the general
mechanism behind therapeutic action lies in
the increased ability to achieve sublation
at various levels of mental representation,
from the life of embodied desire to the feeling
soul and rational cognition (Mills, 2002a).
But this is a continual process that is never
static or complete, for the dialectic is always
engaged in an active process of encountering
new experiences it must continually mediate
and integrate into its psychic interior, without
which, the dialectic, hence mind, would cease
to exist.
We are never unified in our psyche, never
fully cohesive or complete in our being, for
mental life is a meandering stream of entering
in and out of a more fundamental fracturing
of psychic reality that transpires within
spacings of the abyss. We may venture that
such a primal space or tearing of the psyche
radically resists other holistic processes
fighting to achieve synthetic integration
and unification of opposites because psychic
life is organized on sublevels of subjectivity
that tend to compartmentalize and preserve
idiosyncrasies and particularized experiences,
hence constituting its own internal worlds
it safeguards through unconscious fantasy
systems. I have referred to this ontological
process as the institution and emergence of
"unconscious schemata" (Mills, 2010),
the building blocks of psychic reality. Because
there is no absolute discernable locus or
point of synthesis for the plurality of unconscious
life, this ensures, at least logically, that
we all experience fractal gaps in being. And
the persistence and repetition of such psychic
gaps that are presumed to exist and manifest
in us all suggest that all human beings have
a psychotic nucleus or fault-line that can
be breached or occluded given the right set
of contingencies.
I propose that behind every personality structure
lies a psychotic process, whether hiding dormant
or in disquieted abeyance, or percolating
benignly until the right stimulus or catalyst
arouses it from its unconscious slumber. I
do not mean this applies only to clinical
populations, but to all people. Any of us
are capable of having psychotic experiences,
under the right strain or circumstances, even
if this seems implausible upon first reflection.
Following the principle of sufficient reason,
every mental object stands in relation to
its original psychical process; therefore,
we may conclude that the divisibility of the
psyche (including the bifurcation of drives,
affect, imago, and thought) becomes the ontic
foundation upon which mind rests. In other
words, the psyche is fundamentally split,
and out of this antediluvian divide comes
its myriad appearances. This primordial bifurcation
of the psyche is destined to leave a certain
element or remainder mired in negation, conflict,
and destruction, the very qualitative properties
characteristic of psychotic experience.
The notion that experiential gaps in being
are punctuated by the imaginary register yet
remain foreclosed in the real is compatible
with a basic line of reasoning that situates
splitting, primitive projection, paranoia,
persecutory and retaliatory aggression, fear
of externality/the Other, and general schizoid
processes within the early formation of a
sense of self. I would also argue this compatibility
in theoretical models is bolstered by evolutionary
psychology avowing how basic overdetermined
dynamics of fear of predation, injury, mistrust,
need for attachment security, and identification
with familiar objects and environments in
the service of self-stability and survival
are instinctively natural and hard to resist.
Here this leaves us in the dialectical gap
between the fulfillment of drive and desire,
and the pursuit of sublation and completeness
on the one hand, and the inevitability of
failure, dissatisfaction, impasse, and incompleteness
on the other, for we can never live up to
our own fantasies and ideals nor fill the
lack. Whether this applies to the notion that
our self-image is always fractured and imperfect
due to human frailty, to our deep pervasive
needs and unconscious longings that pine for
satisfaction-psychic reality constitutes
a series of spacings that are never whole
or unified, for mind is always in turbulent
flux as being in becoming.
Mind as Projective Identification
In my book, Origins: On the Genesis of Psychic
Reality, I demonstrated how the dialectic
of desire forges the progressive path of ego
development that emanates from the unconscious
abyss of indeterminate immediacy to the determinate
mediacy of the unconscious ego to that of
conscious life (Mills, 2010). Thus, the unconscious
mind is an original undifferentiated unity
that emerges from its immediate self-enclosed
universality to its mediated determinate singularity.
This is initiated through a dialectical process
of internal division, self-externalization,
and introjection as the reincorporation of
its projected qualities back into its interior.
Here lies the basic process of projective
identification: unconscious agency splits
off certain aspects of its interior, externalizes
itself, and then reconstitutes its Self by
identifying with its own negated qualities,
which it re-gathers and assimilates back into
its unconscious framework. Through the complexities
of mediation and sublation, the psyche achieves
higher levels of unification and integration
through rational self-reflection and the attainment
of self-consciousness, thus uniting more infantile
experiences and earlier movements within its
more mature organization.
Negativity, aggressivity, and conflict-the
hallmarks of death-are essential forces
in the thrust of the dialectic, a process
Melanie Klein emphasizes in her characterization
of ego development. The initial forms of the
mind inhabit an undifferentiated void with
the inner ambience of violence. It experiences
the primeval chaos of an intense longing to
fill its empty simplicity, desire being its
form and content, the desire to fill the lack.
Through the drive towards self-differentiation,
the unconscious ego defines itself as a determinate
being-for-itself and thus effects the passage
from the universal to the particular, from
a unity that lacks difference to differentiated
plurality within singularity. There is an
antediluvian cycle of negativity that we may
say belongs to the prehistory of the conscious
subject, a circular motion of the drives that
constitute the dialectic of desire. Awakening
as sensation from its nocturnal slumber, the
feeling soul remains the birthplace of what
is the substance of the "heart," for the
abyss is the midwife of mind.
Klein's theory of splitting has revolutionized
the way we understand ego development. For
Klein, the ego exists at birth 
and is plagued by anxieties characteristic
of psychosis, which it attempts to fend off
and control through the primary defense mechanisms
of splitting, projection, and introjection,
thus giving rise to the paranoid-schizoid
and depressive positions that mold object
relations and psychic structure. Although
Klein refers to these defensive maneuvers
as "mechanisms," they are not mechanistic.
Ego activity is never fixed or static and
does not take the form of predetermined tropisms;
rather, psychic organization is the continuity
of subjective temporal processes distributed
throughout spacings of the abyss. It is more
accurate to conceptualize these early mechanisms
as defensive process systems comprised by
the ego's intrapsychic relation to itself
and its object environment, initially
the mOther. This makes ego development and
object relations an intersubjective enterprise.
In her seminal essay, "Notes on Some Schizoid
Mechanisms," Klein (1946) proclaims splitting
as the original primordial defense, a process
she started analyzing as early as 1929. Beset
by the death drive (Todestrieb), the immature
ego deflects the destructive impulse by turning
it against the object accompanied by oral-sadistic
attacks on the mother's body, thus giving
rise to persecutory anxiety. Splitting is
the very first in a series of defenses that
are never completely separate from one another,
hence forming the dialectical cycle we have
come to label as projective identification.
While Klein cogently articulates the gradual
evolution and strengthening of the ego, she
concedes that "so far, we know nothing about
the structure of the early ego" (p. 4).
Not only must we situate splitting at the
inception of psychic development, but we must
also demonstrate that splitting is the earliest
activity of mind. Splitting becomes the prototype
of mental process and remains a fundamental
operation in the normative as well as in the
pathological functions of the psyche. The
unconscious ego first undergoes an internal
division of (or separation from) its interior,
which it projects as an external object within
its own internality, only to regather and
again make it part of its inner constitution.
This primary splitting activity is architectonic,
thus forming the foundation for psychic growth.
Since splitting is identified as the initial
movement of the dialectic, thus effecting
its transition into mediatory relations, it
becomes easy to see how splitting becomes
the archetype of later ego activity, which
Klein emphasizes in her developmental framework.
But, unlike Klein (1946, 1955) who repeatedly
tells us that the ego's first object is
the mother's breast, it would follow that
the ego's first object is itself-its own
internality. The ego must first posit and
set itself over its initial immediacy, which
it does through splitting.
In its ego explicitness, before the soul makes
its final trajectory to consciousness, unconscious
mind has already undergone a manifold splitting
of its interior by its own hands. In each
incremental process of splitting that accompanies
sublation there is an internal division, projection,
and (re)introjection of its particularization
back into its internality. Each introjective
maneuver is a reincorporation of its projected
interior that takes place through an identification
with its alienated shape(s), which it takes
to be an exterior object possessing, however,
its internal qualities.
But why would the unconscious ego need to
split itself in the first place? Here enters
the force and primacy of denial (Verneinung).
As previously mentioned, the ego's original
activity is one of negation: it defines itself
in opposition to what it is not. Following
Freud, Klein speculates that splitting mechanisms
arise in an effort to subvert the death drive
that threatens the ego with internal destruction.
Splitting is a defense against felt or perceived
annihilation. As I have argued, unconscious
subjectivity first encounters an inner negativity,
aggressivity, or conflict, which becomes the
impetus for dialectical intervention. In fact,
splitting itself is a violent cleaving operation
that divides subject from object. For Klein,
splitting disperses the destructive impulse,
while for Hegel splitting is destructive:
it destroys as it negates. But the destruction
incurred by the cancelling function of the
dialectic is also preserved in the same moment
as the ego sublates itself to a higher state.
Splitting and projection highlight the negative
side of the dialectic while introjection serves
a synthetic function. The repetitive process
of projective identification may be applied
to the general ascending thrust of sublation
or it may succumb to contentious dichotomies
that are mired in chaos. Although the relationship
between the death impulse and negation still
remains equivocal, destruction is nevertheless
a key element in the progressive unification
of the ego. But if the subjective mind is
not able to developmentally progress towards
synthetic rational integration, then earlier
primitive defensive constellations will persist
unabated.
Splitting and the Psychotic Spectrum
Is there a basic fault-line that may be breached
under relatively normal conditions-let alone
times of inner tumult or external crisis-that
may trigger the emergence of a psychotic process?
Rather than view this onto-structural a priori
potentiality as a reified core or reducible
center of subjectivity, I prefer to view this
fault-line as an elementary or equiprimordial
unconscious organizing principle responsible
for instituting division in the soul as a
mode of psychic economy. Rather than view
the psyche as psychotic at its core or foundation,
itself a dubious value judgment, I merely
want to highlight the double character of
the dialectic inherent in both health and
illness. Bifurcations, binaries, poles, and
separations allow for the coexistence of difference
despite their dialectical relations, and this
reiteration of a simple economy allows for
psychic differentiation threatened by diffusion
or dissolution into an engulfing collective
that vitiates all semblances of difference.
Here a certain fear of engulfment and loss
of self in the universal makes sure that difference
is maintained through such divisions or gaps
in being. This means that splitting is a necessary
ontic condition of thought and psychic structure
and not merely a pathological instantiation
or defense.
Given that every human being is preceded by
a psychological attachment system, whether
secure, healthy, faulty, deficit, or morbid,
this means that personality formation first
encounters splitting and division that is
correlated to later psychotic experience.
We may only observe how it appears predicated
on developmental precursors. When splitting
unearths a more fragmentary or traumatic process,
it is more likely to manifest on a spectrum
of psychotic organization and symptomatology,
which I have witnessed in my own clinical
practice. That is, psychosis rarely appears
in the same manner in people, despite the
fact that we have good reason to believe a
typology of psychotic symptoms and disorders
are valid for diagnostic categories and/or
social descriptions. Although negation, itself
a form of violence, is the ontological force
behind the splitting or cleavage of mind,
which is furthermore a generic condition of
thought, the unconscious operation of splitting
objects remains its universal (hence abstract)
form. It is only when particularized developmental,
historical, and cultural contingencies are
evoked that form carries forth tangible content
that become intelligible to clinical sensitivities.
What becomes an important empirical question
that potentially affects the clinical treatment
of the psychotic is whether we should proceed
with the hypothesis that some form of attachment
pathology conditions the emergence of psychosis.
This would further presume that some form
of developmental trauma lies at the bedrock
or essence of symptom manifestation, if not
conditions the etiology of disorders of this
kind. Although I do not wish to make a broad
causal claim or hasty generalization to all
psychotic populations, clinical observation
alerts me time and again to how early developmental
precursors in psychotic patients are correlated
with compromises in early object relations
and attachment relationships, experiential
or perceived relational trauma, and deficits
in psychic structure. I cannot recall a single
psychotic patient in my career who I saw clinically
that did not have some variant of these compromises
in their developmental history. Because of
my own experience, this clinical hypothesis
forms a basis in how I conceive of psychosis
as indices of traumatic attachment.
If we accept the premise that psychosis emerges
on a psychic spectrum, from more benign or
innocuous forms of inner conflict to severely
pathological and disabling conditions that
undermine the health and adaptation of the
human subject, then what role does the dialectic
of division and unification, difference and
identity, splitting and integration mean for
the patient? This dialectic is at the heart
of psychic organization, which ensures that
conflict remains its structural edifice. In
this sense, conflict is at the core of the
psyche in both health and pathology.
Not only is the failure of dialectical mediation
and integration behind the emergence of psychosis,
but so is the inability to float in the gap
of difference-between division and synthesis,
which also seems to be a dynamic behind symptomatic
manifestations on the psychotic spectrum.
The inability to drift in the gap of the gap
becomes problematic for those lacking integrative
cognitive capacities, especially when this
is further blocked on an unconscious level.
On one hand, there is a suspension of an integrative
function that keeps a psychotic stronghold
over the subject; while on the other hand,
there is the failure to be able to suspend
imagined realities as merely being a psychic
projection. In either case, there is an inverse
or double dialectic at work in both normative
and psychotic thought, one being successful
at both mediation and suspension, the other
unsuccessful (even if disproportional) at
performing either function.
If thinking is prefaced on ontological violence,
namely radical negation-the cleaving of
identicalness, then tarrying in the negative
is the onus of mental functioning. But here
we must differentiate ontological negativity
from a phenomenological one. Just because
certain self-states at times feel divided,
nebulous, or incohesive does not mean our
self is in shambles or falls to pieces. These
are usually transitory phenomena at most,
while structurally there is an ongoing sense
of continuity and cohesion of the self despite
its ever-changing dynamisms. Such vital processes
are in fact what fortifies psychic structure
and allows it to sustain, develop, and endure
repeated conflict as a trajectory of dynamic
pattern and temporal flux. It is only when
this ontological tear in the psyche is incapable
of sublating or leaving this divide that psychosis
prevails.
The primordial split or gap that underlies
thought and psychic structure may manifest
in myriad fashions, from obsessive-compulsive
fixations, amorphous confusions, disorientations/disorganizations,
fugue states, merger fantasies, thought disorder,
bodily somatic conversions (e.g., trichotillomania,
anorexia, body dysmorphic disorder), circumscribed
delusions, and so on that characterize schizoid,
dissociative, and borderline phenomena, to
full-blown chaotic and demented presentations
where all semblance of cognitive order is
inconceivably expressed as irreal meaningless
nonsense, incoherent irrationality, and psychic
decay where no persisting cohesive self exists.
Instead, any sense of self resides in the
divide-fractured, maimed, irreconcilable.
What does this mean for clinical theory? Perhaps
not very much. But if the psychotic is besieged
by the inability to mediate and synthesize
dialectical polarities or reside in the ontic
gap of self-relation with all its ambiguities
and challenges to both identity and difference,
integration and diffusion, universality and
singularity, then would not one goal of treatment
be to help the patient tolerate such ambiguities
so they can stand in the spaces, so to speak?
Would not further treatment goals be to help
the patient form social and semiotic links
to help bind the irreconcilable divisions
in his gaps in being? Regardless if psychosis
or the capacity for its experiential manifestation
is derived from normal or pathological development,
patients suffering from psychotic states would
still require a holding environment sensitive
to their emotional fragility and ambivalent
attachment needs. You can never underestimate
how fragile a person can be, let alone what
might set him off or lead to decompensation,
or what may be the link that is broken sustaining
his sanity, or the internal regulator that
is eclipsed from rational decision-making
when under the requiem of madness.
As we have said, psychosis is the failure
of sublation, at least in part, which means
a failure at sublation on the part of the
ego, as well as fixation or oscillating between
fixed presentations (Vorstellungen) and regressive
withdrawal back to primitive shapes of mind
that were once sublated. It is also a failure
of being able to tolerate living in the gap
of division, ambiguity, and fragmentary experience,
that is, residing in the divide between irreconcilable
oppositions. This creates a further ontic
tension for the subject that is very uncomfortable
to endure because attempts at mediating and
integrating conflicting polarities at war
with one another seem to be an impossible
task. Here we may observe in the psychotic
a basic defect or eclipse of a unifying principle
or synthetic function necessary for trussing,
transcending, and resolving intrapsychic fissures.
The inability to sublate opposition into a
meaningful integration based on attacks on
linking and/or in the failure to bind psychic
division and competing dialectics operative
in the mind, and hence resulting in semiotic
foreclosures, seems to be a pathogenic element
in the formation of psychosis. It would logically
follow that introducing intervening cognitive
skills at synthesizing and integrating conflicting
oppositions would be an overarching goal of
treatment, yet this naturally takes into account
working with microconflicts a bit at a time,
not to mention the assault on reason the psychotic
experiences on an ongoing basis. What often
happens in the consulting room is that patients
get better at discerning conflicting stimuli
over time and begin to enter into an inner
dialogue where split-off aspects of the self
come into communication with other alienated
aspects, part self/objects, or microagents,
and this juxtaposition increases the distinctness
of particularity while decreasing its penumbral
conflation with totality, which becomes lost
in universal obscurity. In other words, units
of experience can be identified and analyzed
without taking the unit for the whole gestalt
of experience. A simpler way of putting it
is that the patient is more able to recognize
opposites in the mind as discrete experiences
rather than as an engulfing totality where
all aspects of the self are disoriented or
eradicated.
Trauma, Attachment, and Psychosis
Throughout my clinical career I have yet to
encounter those who are prone to psychotic
experiences to be free of developmental suffering
and attachment disturbances, even if only
minor in scope or intensity. When more pronounced
forms of trauma, abuse, or neglect are identified,
there is always a correlate to how attachment
patterns had developed and are compromised
in relation to feelings of safety, emotional
security, self-cohesion, the construction
of object representations, capacities for
affect regulation, and the formation of psychic
structure. Here we may say that psychotic
symptomatology cannot be separated from attachment
pathology and the presence of developmental
damage. But the interconnectedness between
trauma, attachment, and psychosis is often
more salient when symptomatology emerges due
to posttraumatic conditions.
While I have offered a conceptual argument
that the psyche is originally constituted
through trauma, and that the future experience
of traumatizing events in certain people with
deficit self-structures would necessarily
evoke earlier unsymbolized and complicated
over-expressions of unresolved trauma, I can
envision the possibility that even the healthiest
of people could develop psychotic symptoms
regardless of their preexisting psychic structure.
What this ultimately means is that all human
beings are predisposed a priori to develop
psychotic organizations regardless of biological
disposition or cultural circumstances: it
simply becomes a matter of degree in their
modes of concealment, containment, and manifestation.
In short, we all harbor psychotic tendencies
whether realized or not.
