The Letter, Issue 55/56, Spring/Summer 2014, Pages iv - vi
EDITORIAL
This double issue of The Letter sees the publication of the proceedings of the conference Treatment Challenges in Psychosis: Voices of Difference – Psychiatry and Psychoanalysis in Dialogue held at St Vincent’s University Hospital, Dublin on December 6th 2013. We should consider it remarkable that all ten speakers on the day have contributed written transcripts of their talks for this important issue.[1],[2] It is equally remarkable that a conference such as this takes place at all, allowing for the entrenched positions that psychiatrists and psychoanalysts can assume when it comes to their contrasting approaches to a topic such as psychosis and its treatment. Since 2008, this, the fourth in a series where we have come together to enter into dialogue on the topic of psychosis, is the second in the Voices of Difference series, where we are taking as our focus the treatment challenges that it poses.
Let us begin by looking at an example in the Irish context of how psychoanalysis and psychiatry can work together. James O’Connor gives us a personal account of how he has come to establish a locus for psychoanalytic work with the Dublin North Mental Health Services. And his colleague in the same service, psychiatrist Malcolm Garland, in his ‘Brief reflections from the front line..’ adds his support for O’Connor’s endeavour, while giving emphasis to the limitations of the medical model in psychosis treatment. This might serve as a beacon of hope for those of us who are confronted by a low tolerance for psychoanalytic practice within the public psychiatric service. However, ‘the Irish situation’ falls short of what has been realised in other jurisdictions.
How the issue is addressed elsewhere is eloquently brought to our attention by Tom Dalzell and Bent Rosenbaum in their respective papers. The actuality
of The 388 in Québec City, described by Dalzell as a clinic for the treatment of psychosis ‘after Lacan’, allows psychoanalysis to function, while supported by bio-social interventions, in a quite revelatory way. Equally significant is Bent Rosenbaum’s account of the Danish National Schizophrenia Project where he was a lead investigator. This project involved fourteen psychiatric units across Denmark, where the merits and demerits of manualised supportive psychodynamic psychotherapy for patients with first-episode psychosis were compared with ‘treatment as usual’.
Such tangible progress aside, let us not shy away from what remains at the heart of what both unites and separates psychiatrists and psychoanalysts. This is the clinical encounter with the ‘thinking’ of the psychotic, ‘(a) structure into which psychiatrist and patient, psychoanalyst and analyser are plunged’, according to Christian Fierens. This is where lack itself, he continues, ‘opens a new kind of thinking’. This ‘new kind of thinking’ is what the theory of Lacan proposes. Mindful of the sub-theme for the conference - the challenge of therapeutic engagement with someone suffering from negative symptoms - this ‘new kind of thinking’ has to be taken very seriously. In his paper, Fierens emphasises how an approach that does not view negative symptoms as a sym- bolic deficit, as ‘a lack which can or can’t be be filled in’ is what allows the question of the subject to be posed, a question prior to any possible treatment of psychosis cf the title of Lacan’s 1956 paper. In my own contribution, I have attempted to ‘colour in’ or give clinical substance to the possibility of such an approach that takes as its starting point ab-sens, differance, the necessity of a ‘clinic of failiure’ etc – all highly specialised terms in Lacanian theory as outlined by Fierens in his latest book The Psychoanalytic Discourse. A Second Reading of Lacan’s Etourdit.
Why ‘a clinic of failure’? The psychoanalyst speaks about a clinic that disappears at the moment it is spoken about – allowing no reproducible, con- sistent findings, and no measurable evidence base to emerge. But, as Barry O’Donnell decribes it, the mental is unstable and destabilising, requiring that the practitioner should have support to handle this without demanding it to be stable, to handle it in its instability.
The nub of our mutual difficulty remains then, that, on the one hand, the psychoanalytic approach to any treatment - unstable by its very nature - cannot find traction or even be judged to have relevance by the non-analyst. While, on the other hand, the non-analyst is judged by the analyst to have closed
down the question of the ‘subject’ by means of pharmacologically driven interventions. Can this mutual difficulty ever come to be what allows us go beyond our incomprehensions and our prejudices?[3]
In their paper, Sheila Clarke, Elizabeth Lawlor and Mary Clarke who have responsibility for DETECT, the early intervention for psychosis programme in South County Dublin and Wicklow, rightly emphasise that the patient has to be willing to engage with treatment and individual interventions in a sustained manner, psychoanalytic or otherwise. This, however, surely prompts a further consideration, as to the possibility of mainstream psychiatric interventions being leavened by or intercalated with a different kind of independent listening which is strictly psychoanalytic. Might not the patient then be more willing to engage with such a service in a more long-term fashion? Or is this a danger- ously utopian aspiration? As Barry O’Donnell puts it, etymologically, a ‘condition’ is ‘a saying with’, con + dicere. Can such a distinction come to matter?
Perhaps it can. When we listen to Joanna Moncrieff on the limits and hidden human costs of pharmacologic intervention in psychosis, she leaves no room for complacency for anyone, least of all patients and their families. Her account of how, in the space of sixty or so years, anti-psychotics came to be promoted as correctives of an underlying abnormality in the brain, purported to be somehow ‘causative’ of schizophrenia is sobering – the so-called disease-centred model of action. The evidence she cites for the effect of antipsychotics on brain tissue mass should equally trouble us.
We will conclude with two recommendations put forward by Cormac Gallagher. Firstly, in listening to our patients we must try to actively rid ourselves of MSP – malignant social psychology. This is a term coined by Tom Kitwood to describe how we treat patients suffering from dementia differently, once they have been labelled with such a diagnosis. Is this any different for someone suffering from psychosis? Secondly, he advises us to develop a ‘poetic awareness’ in relation to what the patient is saying or not saying.
With such encouragements, blessed indeed are the peace-makers, ...the pace- makers, ...the pace-setters.
Let us aspire to be among their ranks and continue to talk to each other.
Patricia McCarthy
References
[1] The papers from the conference are presented in the sequence in which they were delivered on the day.
[2] Because of space considerations we are unable to publish the discussion that took place at the end of the conference in the present issue. Chaired by Professor Brendan Kelly, Consultant Psychiatrist, Mater Hospital, Dublin and Professor of Psychiatry, University College Dublin, the discussants included: Dr Richard Blennerhassett, Clinical Director and Consultant Psychiatrist, St John of God Hospital, Dublin; Mary Cullen, Manager, Mounttown Neighbourhood Youth and Family Project and Member of The Irish School for Lacanian Psychoanalysis (ISLP); Donat Desmond, Psycho- analyst, Derry, Member of ISLP and BACP; Dermot Hickey, Principal Social Worker, St John of God Hospital, Member of ISLP; Dr John Lyne, Senior Registrar, Coolock Mental Health Centre; Dr Ronan Mullaney, Senior Registrar, National Forensic Health Service; Dr Emer Rutledge, Consult- ant Psychiatrist, Our Lady’s Hospital, Navan and Dr Consilia Walsh, Consultant Psychiatrist, St Vincent’s University Hospital, Dublin
[3] Recalling Niels Bohr’s ‘No paradox, no progress’.