Abstract
What meaning is to be discerned in the phenomena of madness? I must declare a bias in this regards, as I remain convinced that the content of delusions and hallucinations retains a strict relationship to the fundamental existential questions and truths of the human condition, as well as to the particular history of the individual. In other words, the role of neurobiological processes is not causative but secondary, and the original problem remains within the symbolic dimension and determinants of the human psyche, both in its neurotic and psychotic conditions. As such, I welcome the existence of such books as this which, at the least, proceed from a conviction that psychosis should continue to engage the interest of psychiatry beyond biological research and diagnostic categorization. There is, however, a gulf between the different theories put under the flag of psychoanalysis by the adherents to the various post-Freudian schools, that is probably greater than that between the analysts and the neuroscientists!
This book arrives under the banner of ego psychology, a predominant paradigm in the United States of America. As this particular theory forms the whole foundation for treatment described in the book, the weight a reader will give to the pronouncements contained within, will no doubt depend on how much one subscribes to the tenets of this approach. Whilst this may limit its broad appeal there is much to stimulate interest and questions in respect to the origins of the undoubted ego dysfunction to be encountered in psychosis.
The author writes: ‘there are biological factors in the aetiology of psychosis which operate especially at the ego apparatus level… How do these ego functions get damaged? No one knows.’ In my opinion, one of the deficits of this book is the lack of discussion to clarify or consider the rationale underlying the assumption that the primary abnormality is in ego function. There is no attempt at a comparison with the theories of psychosis as worked by many other psychoanalysts, in particular the Kleinian or Lacanian versions, wherein the ego dysfunction may not be accorded such a primary position.
The book begins by describing the basic structure and function of the ego in regards to defences, boundaries, object relations and reality experience and is well organized using both text and tabular format. Subsequently the particular dysfunction of the ego in various conditions designated as psychosis and near psychosis are enumerated, along with interventions for each of these circumstances. I found the attempt to reformulate the borderline states in terms of near psychosis at times ambiguous and I wonder if such a nosology leads to any clarification of these already muddy waters.
There are a number of reasonably concise verbatim therapist–patient interactions related as illustrations of technique which make interesting reading. As always when considering such clinical material, one is drawn into comparison with one's own experience, where working with psychotic individuals rarely seems to go as smoothly as described in these examples!
Finally there is a short discussion, too curt for me given its primary importance, of the transference phenomena in psychosis. ‘Psychotic transference must be recognized early, avoided or confronted immediately, questioned and or refuted emphatically, and analysed methodically.’ Easier said than done!
Overall this book conveys the author's commendable ongoing interest in the difficulties encountered in the treatment of psychosis and I would recommend it to those who similarly retain a commitment to the questioning of meaning that this work should entail.