Recently, within the context of long-term psychotherapy, particularly within the context of the relationship between the therapeutic partners, I observed the emergence of a somatic delusion which was imbued with relational and intrapsychic meaning. I shall give a brief description of this event. First, I would like to point out that I do not believe such processes can be reduced to the neural regions which mediate them. In neuroimaging research (PET, fMRI) of persons with delusions, the following areas are affected: limbic areas are hyperaroused and prefrontal areas are underaroused (this is a similar neural signature observed in research on profound stress -- amygdalar arousal can be associated with hypofrontality).
The person and I were doing a phone session due to the transit strike in New York. He noted that he would like to take a bus trip to visit his mother in a distant state. He said that he prefers the bus rather than flying because he is afraid of the latter. Immediately, he noted that a persecutor was stomping upon his head. I explored with him the connection between flying and this experience of being stepped on. Recently, he has made some strides in tolerating the painful feelings which he tends to defend against through denial and projection -- establishing a sense of victimization and blame of others (the latter being a barrier to forming close relationships. Because of his vulnerability to a sense of annihilation of self whenever he feels deeply ashamed or defective, he has not been able to establish any friendships. He has lived a very isolated, solitary life for many years). He immediately said that he felt he was a “coward” for not flying. Recently, he was aware that I had to fly to another country to participate in a conference. We were able to go only so far in making these painful feelings of defect in his self (in relation to his therapist) conscious. I felt to go further would have been to rub salt in his wounds (on two prior occasions, when I had good things happen to me, which he found out about -- seeing a wedding ring and getting copies of his Medicare payments paid to me -- he had relapsed into crack binges, which we were, over time, able to associate with his painful feelings of being left behind, having less, etc.). His emergent delusion of being stepped upon, seems very similar: stepped upon by his feelings of being defective in relation to others which quickly gets concretized into a somatic state of persecution, persecuted by his own feelings of being inferior and ‘less than’ others. It is important to note that this man was raised by a highly critical and competitive father who seemed to have a need to humiliate his son in relation to himself.
Another of my patients maintains a very rich, interesting and complex systematized delusional life which stands in stark contrast to the impoverished, lonely, isolated life he is actually living. For me, a first step to his no longer needing these rich delusions is for him and me (he relates with no one else -- persons avoid him whenever he relates his delusional ideas, and he avoids others whom he feels can contaminate him with germs, etc., a reflection of his vulnerability to feeling controlled and colonized by others) to develop an emotionally rich relationship which can ‘compete’ with these delusions. In the meantime, his family pressures his various psychiatrists (who sooner or later get ‘fired’ by his family because his delusions are not eliminated by the many different agents and dosages he has been placed on) to keep raising his dose of antipsychotics. Over the years, I have never seen any effect whatsoever of the various agents (or his psychotherapy) upon his delusional life. I do believe that his delusions, as pointed out by Harold Searles long ago, in his theory that psychotic symptoms can serve transitional object functions for the patient-a sort of security blanket -- and the need for these symptoms to become transitional objects for the therapist as well, in order for them to be successfully resolved -- to this I would add, the importance for the patient to be able to establish a relational, social context which could eventually take the place of delusional certainty and containment. The article by Searles, which he informed me was an article he felt was one of his more important contributions to our field, is "Transitional phenomena and therapeutic symbiosis" is contained in his superb 1979 volume Countertransference and Related Subjects: Selected Papers).
These situations could never be reduced to the molecular interactions and neural events, observed by neuroimaging scans, without vital information being lost in the process. It is deeply troubling to me that many in our field continue to view these ‘symptoms’ as evidence of disturbed neurodevelopment alone and in need of psychopharmacological correction without helping the individual achieve a greater sense of relatedness and autonomy through the establishment of relational, affective insight into the problems that plague her or him. Medications can be likened to helping to quiet the turbulent waters surrounding the patient (although I have seen countless times, that relational containment and insight can also achieve this) and relational insight is like providing a better paddle and boat in which the patient can more effectively navigate the stormy seas which are inherent in the human condition.
Brian Koehler PhD
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net
