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20° Congresso dell’ISPS (Società Internazionale per l’Approccio Sociale e Psicologico alle Psicosi).
Liverpool, 30 Agosto-3 Settembre 2017.
Title: Psychodynamic Psychotherapy for Psychotic Patients: Relevance of Dreams and of the Emerging of the Human Potential.
Presenter: Michele Battuello.
My model of Psychotherapy is combined individual/group Psychotherapy starting from individual, proceeding with combined individual/group and ending with the group only.
What I’m supposed to highlight today is the role of dreams in Psychotherapy as the tool we have to recollect the unconscious images of the first years of life and their fundamental significance for patient’s treatment.
This clinical process is central for the evaluation of the possibility to start a Psychotherapy also with psychotic patients.
The clinical experience is the main chance to have a picture of the person: specifically in terms of Psychodynamic Psychotherapies supervision must be associated to participation to Groups and their dreams.
For this reason in our Centre in Rome (Centro di Psicoterapia di Roma), we work also on research and education and psychotherapists and/or students attend Groups as myself did.
I want to enhance the role of dreams for the comprehension, elaboration and transformation of the patient’s development since birth.
Dreams that must be used, listened to and interpreted: what I see in present times is the devaluation of their role for the understanding of the very early dysfunctional dynamics and of the process of growth of the baby to restore it when failed in some steps.
Many patients as psychotic ones present complex clinical features and symptoms that make difficult the evaluation for a Psychotherapy.
Inside the large group of the Psychotherapies of the unconscious, initial sessions are usually focused on exploring patients’ inner world, relations, history and psychopathology and the psychotherapist tries at his/her best to understand what’s going wrong with that person.
The psychotherapist can decide to start a Psychotherapy basing mainly on dysfunctional aspects.
This limits the possibility for Psychotherapy because the seriousness of symptoms and pathological dynamics seems to be the distinctive element that allows to work with the patient or not.
So often “severe” situations are subjected to a Psychiatric evaluation and to a pharmacotherapy and follow another clinical path while less severe patients can start a Psychotherapy.
Just because we don’t work in groups with patients selected for pathology but we prefer a heterogeneous vision of human’s dynamics, we consider to work with psychotic patients as for all of our patients, after the two important steps of evaluation sessions and a period of individual therapy.
Our methodology is focused on Group Psychotherapy, considering it the best way to work in Psychotherapy. We use an integration of individual and group Psychotherapy as follows:
- First evaluation sessions (up to 6 and more).
- Individual therapy
- Combined individual and group therapy
- Group therapy
Our groups are medium ones, up to 12-14 patients, open access for pathology, age, sex, starting and ending.
Our approach is based on interpretation: of dreams and of the relation.
So interpretation assumes a double role during Psychotherapy.
Interpretation comprehends both the frustration of pathological issues both the strengthen of valid parts emerged as manifestation of the physiological human potential.
Let’s go fast through the developmental process.
Since birth to adolescence all the moments of affective significance in the relation of the child with the mother first, then the father and all the others relevant, will leave unconscious traces in the mind.
These traces are represented by images emerging from dreams that show the progressive establishment of the sense of Self and the subsequent ability to invest the same Self in the realization of the identity (that are the relationships).
The more the child is able to separate him/her self from the mother, the more at adolescence the image of the mother as physically herself will disappear for a completely new image that corresponds at the identity of the adult.
It is the result of an unconscious act of creativity. The phantasy is free to create an autonomous possibility of Self.
When this transformation is not possible the adult will look for affective situations in which the unconscious expression is represented by images of identification, control, assistance, dependence etc. that are fixed and fastened.
The phantasy has been mortified by the defense mechanisms.
Psychotherapy gives the chance to experience or re-experience this unconscious transformation if the developmental process failed. It can be considered as the restoration of the identity.
The progression of the psychotherapeutic work and the resolution of the internal conflicts show that as at adolescence, patients start to transform the fixed image of the precedent affects (mostly the mother) in a completely new, personal, subjective image that is the identity.
When the psychotherapeutic work let emerge dreams that have the significance of arriving at adolescence, the Psychotherapy ends and it is possible to listen to dreams that show the transformation of the same psychotherapist and/or Psychotherapy generally condensed in images full of phantasy.
I think that we all are very happy that today neurosciences are integrated with psychological sciences but at the same time I really find a lack of my personal comprehension of how all the findings we have of the baby and the relationship with the mother are used inside the Psychotherapies of the unconscious.
This integration shows the relevance of first years of life for the development of the baby.
So, if we all agree that the baby is sane since birth and the relevance of the relationship with the mother is widely recognized for the process of construction of the identity, the emerging unconscious of that period is central for Psychotherapy.
Our job brings us to the same conclusions of neurosciences arriving from the opposite side of the Human being, the patient (the adult) therefore we can absolutely explore the first years of life in which the irrational life is prevalent.
The double activity of understanding when the relationships of this period failed and at the same time when they were effectively valid is the real possibility for the patient to recovery and we have one special tool for all this.
I refer to dreams and their interpretation. What is clear in my experience is that together with the internal conflicts and pathological dynamics, dreams represent perfectly how was the development of that person and how it is repeated in the adult behavior.
Since first sessions, our proposition is explicit with the aim of activating an answer that is reachable by dreams and by relation.
Patients usually concentrating on their symptoms, problems and conflicts in a circular loop with no way out, find a different perspective, an explicit request to work with the aim of let emerge what we call the valid human potential as a quality of human being.
The relation becomes quickly strong for many reasons:
- A proposition of psychotherapy where is considered recovery’s possibility.
- A proposition of searching not only the pathology, the “bad” parts of the person, but mostly the valid, affective and functional ones.
- A proposition of leaving to the patient the time he/she needs to become an active part of this work.
The valid psychotherapeutic alliance that appears as the answer to psychotherapist’s proposition, represents the awareness of patients that we could call the “physiological” elements, the not destroyed ones, that are still present.
They can be covered by symptoms, by pathological dynamics, by severe illness, but they can be still present in traces and when patient can reach them, is an indication for beginning a Psychotherapy and a positive predictor factor for recovery.
For psychotic patients during the evaluation sessions I am used to wait the time the patient needs to let emerge dreams that show even a small nucleus of protected parts of the Self.
I consider them the physiological/valid ones that at that time don’t request an interpretation but are a communication of the possibility to work together.
Many times evaluations sessions of psychotic patients least 2-3 months to establish a strong therapeutic alliance that concretely is an active work but the communication at the patient is “we still together are looking for something clearer, stronger to work with”.
By the patient’s side this time allows him/her to feel quite and confortable in the relation because there’s no hurry to do something, but at the same time there is the knowledge of an active participation of him/her in to the psychological work looking for what is functioning in everyday life rather than not.
The common and main answer I give them at the beginning is that anyway I don’t accept the representation of a closed circle of dysfunction: in every session even in the last few minutes we have to find an open access to validity.
Clearly as in other kind of patients, mostly in psychotics, all these elements could not emerge: it doesn’t mean that he/she can’t start a Psychotherapy but it’s not the right moment and I always give them back the certainty that is better to proceed with pharmacotherapy but there could be a time also for elaboration.
In my experience if patients can stand the first evaluation sessions, generally the psychodynamic work can start and proceed successfully.
We think that psychotic aspects of risky patients are the ones that request the comprehension and the elaboration inside individual Psychotherapy: in those patients the valid parts are still present but very fragile and covered by disruptive ones.
The pathological dynamics are prevalent and the defense mechanisms activated to maintain the status quo.
As everyone knows from his/her own clinical experience one step the Psychotherapy goes forward the next session maybe goes back.
During the first period of individual Psychotherapy is difficult to use interpretation of dreams as tool of the psychological work because psychotic patients can’t tolerate at all the interpretation of pathological dynamics as the presence of valid and functional parts for the tendency to disruption.
This doesn’t mean that it is not possible to use dreams for the psychotherapeutic work.
I request dream telling during initial treatment of psychosis because it is very common to find that delusions and/or hallucinations are described inside dreams.
They explain the origin of the psychotic features and it is possible to understand how a terrifying or anguishing dynamic has been put out of the unconscious and represented in reality.
When I realize it I generally give back to the patient the communication that his/her experience (mental or sensorial) can be considered as an outflow of something that we have to put inside again because it’s the right place to be even if temporary is elsewhere.
Many times this communication is enough to give to the patient a concrete information/meaning to what’s happening using the metaphor of the overflow.
Progressively this feedback continues to activate an unconscious process so the rational comprehension can come together with the internal evolution of the patient ‘til when it is possible to start the interpretation of dreams.
During this process a big deal with psychotic patients is the level of tolerance of what is working and improving.
The confidence with an incoming small and progressive well being is hardly tolerated, therefore it is the hardest phase of psychotherapy.
Apparently paradoxical but really understandable the patient swims better inside psychopathology during the psychotherapeutic process because he/she is confident with it.
At the moment that something is better seems that he/she doesn’t have the skills to manage it therefore mostly in psychosis a good outcome is initially experienced with euphory and detached happiness or at the opposite side with strong aggressive attacks.
When I perceive from dreams and relation that this moment is occurring I generally try to conduct, directly or not, the patient into a depressive “mood” or “attitude” to fasten him/her to affective reality.
When patients in individual Psychotherapy passed through the initial phase, interpretation of dreams and of the relation and frustration of the pathological dynamics is possible and so Psychotherapy continues with the elaboration of personal history and inner dynamics.
The human potential emerges as a more prevalent part of patients and the sense of emptiness and anguish of psychotic aspects are substituted with an affective presence, considered as a phase of valid depression.
When personal issues are becoming not so prevalent and patients can come out from their own world in which they had concentrated for so many years, in a circular loop of symptoms, altered reality and thoughts, the psychotherapist can extend Psychotherapy’s work to socio cultural aspects in order to insert them in the group.
The evaluation of patients’ answers allows to understand the right moment to bring patients into the group.
At this time individual and group Psychotherapy proceed together: it’s important to evaluate the patient’s reaction to the group both inside group Psychotherapy both in individual where there’s still space and time for private issues.
What patient can’t stand in the group yet or thinks that can’t stand, has still a personal and private time to be faced. Individual Psychotherapy can stop when the patient elaborates an unconscious image of separation from the psychotherapist: we search this image as a first step of the definitive separation from the group Psychotherapy.
Psychotherapy then continues only into the group until it ends: the work is the same of a standard psychotherapy where the more severe, intolerable dynamics are faced and elaborated and where the psychotic aspects that can emerge anyway are well known and understood by patients and so can be tolerated and elaborated by the group.
The psychodynamic subjects become a skill for patient to interpret the socio-cultural aspects of social dynamics.
Efficiency of this method is divided in three points:
Advantage for the single patient: psychotic patient mostly can find a first period of privacy, an intimate space, a container for traumas, anguish, fears and despair. In the group there’s a decrease of transferal resistance as of acting out and drop out, and at least there are economic advantages.
Advantages for group dynamics: decrease of aggressive behaviors and interpersonal conflicts, improving of climate group, attenuation of hierarchical levels among patients.
Advantages for the Psychotherapist: continuous monitoring of psychotic patients with decrease of counter-transfer dynamics.
In conclusion, for psychotic patients the possibility for a Psychotherapy that contains the goal of recovery is possible not stopping at the diagnosis and at the clinical issues but exploring the valid and affective part left into the patients, the human potential.
The initial period of individual Psychotherapy is important to contain what became impossible to be contained by patients and also to redefine problems in terms of facts and relations to allow them to access to their inner world, to find an insight to proceed with the interpretation of dreams and of the relation.
Then the Psychotherapy extend personal dynamics and conflicts of single patient to the group the best skill for psychotic patients to come out from the circular world in which they continuously lost themselves and open again to the interplay between humans.
Michele Battuello