Living with Psychosis
Paula Conway & Andreas Ginkell
a psychodynamic development model
of psychosis
and its psychosocial application
ISPS UK
October 2012
Living with Psychosis
Every professional, as well as every relative or carer, has
experienced the frequent and specific difficulties that people
affected by psychosis have with engaging in or interacting
in relationships.
This includes anxieties about personal, social contact and
difficulties in interpreting the intentions of others,
characteristically leading to withdrawal.
These difficulties in social interaction experienced by
people living with psychosis pose a dilemma, as treatment
and support inevitably require relating and social
interaction.
Living with Psychosis
In our presentation today we are proposing that these
difficulties in relating and socially interacting, which are
characteristically affecting people living with psychosis, are
due to developmentally established psychosocial
disability.
The nature, origin and expression of this psychosocial
disability becomes specifically visible from a
psychodynamic point of view
Living with Psychosis
The psychodynamic development model of psychosis
formulates this view and aims to:

provide a model and language for addressing the
specific psychosocial difficulties experienced by
people living with psychosis

make psychosocial disability more visible and its
consequences predictable

provide a pragmatic guide to supporting the
psychosocial needs of people living with psychosis
and furthering their recovery and social inclusion
Living with Psychosis
acute episodes
positive symptoms
psychosocial disability
negative symptoms
psychosocial dysfunction
social withdrawal
prodromal / remission
Living with Psychosis
The psychodynamic development model proposes
that:
The psychosocial disability
underlying psychosis is an
inherent risk of the
specifically human processes of
development and maturation
of the human ‘social brain’.
Living with Psychosis
The evolved human maturational processes
Evolution has resulted in human babies being born
extraordinarily immature and absolutely helpless.
Brain growth and structural development are accelerated
after birth and continue well into early adulthood.
Brain / neuro development is responsive to environmental,
i.e. social interaction.
The human brain is a ‘social brain’ = mind.
Living with Psychosis
The psychodynamics of the evolved human maturational processes
D.W.Winncott observed and described in psychodynamic
terms the experiential processes of this evolved human
maturation.
mother – baby unit
omnipotence
phase of total helplessness - absolute dependence on maternal care –
there is no such thing as a ‘baby’
mother has objective omnipotence – baby has ‘subjective’ illusion of omnipotence
baby’s primary
narcissistic omnipotence
Living with Psychosis
I
PARANOID /
SCHIZOID
POSITION
good parts /
experiences
bad parts /
experiences
states of mind
states of mind
annihilation /
persecutory anxiety
splitting / projective
identification
mother – baby / infant unit
absolute dependency on maternal care
primary narcissistic omnipotence
Living with Psychosis
birth of subjectivity
I
PARANOID /
SCHIZOID
POSITION
good parts /
experiences
me
bad parts /
experiences
states of mind
states of mind
she
annihilation /
persecutory anxiety
splitting / projective
identification
mother
– baby
/ infant
unit
beginning
of me
/ not-me
differentiation
absolute dependency on maternal care
absolute dependence on maternal care
primary narcissistic omnipotence
subjective omnipotence
Living with Psychosis
Subjective Triangulation
I
•
me
she
subject – object differentiation / Subjective Triangulation
relative dependence on maternal care
subjective – objective omnipotence
Living with Psychosis
Subjective Triangulation forms the basis for Oedipal Triangulation
subject
I
Is the other in her mind
me?
-
other
I am another !
I am competing with
others for this place in
her mind
me
myself
self
she
her
she is
also an
object
She has
also a
mind
like mine
I
she
I
subject
her
self
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
his / her
other’s
I
his / her
other
I
me
my
other
she
her
I
her
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
his / her
All relationships,
social interactions
are inescapably not
just between two
people! Every
relationship is
inherently affected
by a third element
– the other!
me
my
DEPRESSIVE
POSITION
depressive anxiety
I
other
=
identified
repression
desire / guilt
she
her
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
A person’s ability to
process the
emotional
challenges of
oedipally
structured social
life in the
depressive
position constitutes
an ordinary good
outcome of early
development and
socialisation
me
my
his / her
DEPRESSIVE
POSITION
depressive anxiety
I
other
=
identified
repression
desire / guilt
she
her
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
However, how does a person who
operates from a
paranoid schizoid position
cope with social life?
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
his / her
PARANOID /
SCHIZOID
POSITION
I
other
annihilation /
persecutory anxiety
splitting / projective
identification
me
my
Idealised
=
primary
narcissistic
omnipotence
she
=
persecutor
her
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
Oscillation
between functioning
in the Depressive
Position and
operating in the
Paranoid Schizoid
Position does
happen.
me
my
his / her
I
other
=
identified
she
DEPRESSIVE
POSITION
her
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
his / her
I
me
my
PARANOID
SCHIZOID
POSITION
other
Idealised
=
primary
narcissistic
omnipotence
she
=
persecutor
her
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
his / her
I
me
my
other
=
identified
she
DEPRESSIVE
POSITION
her
Living with Psychosis
Why do some people ‘interact’
with life more than others
in the paranoid schizoid position?
Living with Psychosis
The foundations for the functional structure
for the psychosocial mind are based in the
earliest relationship with mother and how the
baby’s omnipotent needs were met.
mother – baby unit
omnipotence
Living with Psychosis
Developmental Origins of the Psychodynamic
Functional Structure of Mind
ID
primary narcissistic omnipotence
MOTHER / OBJECT
subjective omnipotence
EGO
secondary narcissistic omnipotence
PSYCHOTIC PART
objective omnipotence
SUPEREGO
Living with Psychosis
Oedipal Triangulation forms the basis for Social Interaction
his / her
I
psychotic part
me
my
other
Idealised
=
she
primary
narcissistic
omnipotence
PARANOID /
SCHIZOID
POSITION
=
persecutor
her
Living with Psychosis
How does the presence, impact,
interference or dominance of a
psychotic part manifest in
every day social life?
Living with Psychosis
tasks
of of
social
living
tasks
living
MIND – Social Brain
non-psychotic part
accepts
 responsibility
 limitations
 change
 dependence
 separation / loss
 ambivalence
 competition
 aggression
 desire
 guilt
psychotic part
rejects
responsibility 
limitations 
change 
dependence 
separation / loss 
ambivalence 
competition 
aggression 
desire 
guilt 
motivational conflict
Living with Psychosis
ethical reversals
The motivational trajectories of the psychotic and
non-psychotic parts of mind are diametrically
opposed.
What is ordinarily viewed as ‘good’ from a nonpsychotic perspective is fundamentally ‘bad’ or
‘dangerous’ from the perspective of the psychotic
part.
This leads a person vulnerable to psychosis to be
plagued by self-defeating doubt and ‘ethical
dilemmas’.
Living with Psychosis
ethical reversals
The presence of the psychotic part of mind is identifiable in behaviour
and communication through the expression of characteristic
ethical reversals:
non-psychotic part
psychotic part
Good = Good
Good = Bad
Bad = Bad
Bad = Good
no ambivalence !
but either or, black or white
absolute ethics
Living with Psychosis
ethical reversals
good = bad
love = hate
responsibility = exploitation
gratitude = accusation
concern = exposure
help = humiliation / debt
...
Living with Psychosis
ethical reversals
non-psychotic part
reality
 responsibility
 limitations
 change
 dependence
 separation / loss
 ambivalence
 competition
 aggression
 desire
 guilt
psychotic part
omnipotence
 entitlement
 limitations denied
 change resented
 dependence denied
 separation / loss resented or
denied and source of grievance
 either or / black and white
 aggression denied or
projected onto other and
perceived as persecution
 guilt categorically denied
 desire denied
Living with Psychosis
ethical reversals
From the perspective of the psychotic part, anxiety
in the ego is experienced as persecutory anxiety.
The inherent narcissistic omnipotent response of
the psychotic part is to rid the mind of experiences
of persecutory anxiety or, if this proves
unsuccessful, to retaliate.
Therefore, the psychotic part, from a quasi
superego position, attacks the ego (or the object in
borderline psychosis) for its ‘weakness’ of letting
anxiety emerge and thus violating the reversed
‘ethical codes’ of the psychotic part.
Living with Psychosis
engagement and intervention
Clinical and support interventions for people vulnerable to
psychosis benefit from taking into consideration the relative
presence and impact of a psychotic part of mind.
This involves the recognition and consideration of the presence
of narcissistic omnipotent motivation interfering in ordinary
tasks of living and relating – and of course in the professional or
caring relationship.
Without this recognition interventions risk provoking the
sensitivities of the psychotic part with consequent increased
withdrawal and/or psychotic disturbance (negative therapeutic
reaction).
Living with Psychosis
engagement and intervention
It is critical to bear in mind that any intervention will be
evaluated by conflicting motivational ethics
– non-psychotic vs psychotic.
What may be considered ‘good’ from an ordinary perspective
and support the non-psychotic part, will be seen to be ‘bad’
from the perspective of the psychotic part.
Maintaining engagement with both parts of the personality is
both the challenge as well as the therapeutic driver of change /
development / recovery
Living with Psychosis
engagement and intervention
Communications with a patient / client / service user need to
bear in mind, acknowledge, accept and address both the
psychotic and non-psychotic parts of mind.
For example:
Acknowledge:
‘You said that you want to do this, but I think a part of you is
concerned and does not want to do it’
Accept:
‘I think we need to accept that a part of you does not want to do this;
yet another part does, and it is important that we keep both views in
mind.’
Address:
‘I acknowledge and accept your concerns, but I don’t think that this
can be done in an either-or, all-or-nothing way. Whether you do or
don’t do this – there will be consequences, either way – it is difficult.’
Living with Psychosis
engagement and intervention
Engagement with the psychotic part requires diplomatic
negotiating of narcissistic omnipotent demands or rejections of
social relations.
Engagement, support and therapeutic work with people
vulnerable to psychosis, is akin to being a peace negotiator
mediating between the conflicting motivational ‘ethics’ of the
non-psychotic and psychotic parts of mind.
The psychodynamic development model of psychosis is not
primarily intended as a specific treatment model but as a guide,
to better engagement and containment of psychotic interference
when working with and supporting people affected by psychosis
across the range of services and modalities.
Living with Psychosis
engagement and intervention
 working within omnipotence / delusions
 awareness of and working within transference / repetition
compulsion
 desire for change vs anxiety about / rejection of change
 reassurance can lead to negative reactions
– ethical reversal
 maintain relational frame / therapeutic stance
 negative therapeutic reaction
 not cure but ongoing negotiation of motivational conflict
 focus on real life – psychosocial change / outcomes
Living with Psychosis
Thank You
Paula Conway
Consultant Clinical Psychologist
Director Grow2Grow
and Life-Work Training and Development
Andreas Ginkell Psychoanalytic Psychotherapist
Director Jobs in Mind
and Life-Work Training and Development
www.life-work.co.uk
a.ginkell@jobsinmind.org
07904616699