Antipsychotic treatment with classical neuroleptics: The patient's experience
This work was supported by grants from the Swedish Council for Planning and Coordination of Research (Forskningsrådsnämnden, FRN) and from The Stockholm County Council Fund for Research and Development. The author is a training analyst of the Swedish Psychoanalytical Society and a research psychologist at The National Centre for Suicide Research and Prevention of Mental Ill-Health, Box 230, S-171 77 Stockholm, Sweden
Sixteen psychiatric patients were interviewed about their neuroleptic medication. Five had used classical low-dose neuroleptics for less than six months, six for more than five years, and five had discontinued previous long-term treatment. Whereas the short-term users emphasized that the medication was a source of safety, others complained about side-effects and that the treatment did not ameliorate anxiety-provoking angry fantasies. Dreading psychotic relapse, many participants faced a dilemma over continuing treatment. Masochistic aspects of treatment compliance and suicidality among psychiatric patients are discussed, as are differences between diagnostic subgroups in coping with the effects of classical neuroleptics.
Antipsychotic treatment with classical neuroleptics: The patient's experience
Throughout the neuroleptic era, from the 1950s till now, the effectiveness of antipsychotic medication in alleviating psychotic symptoms has stimulated great optimism among clinicians. A vast literature focuses on the beneficial effects of neuroleptic drugs. Even though a range of motor side-effects caused by the dopamine-antagonistic action of the treatment are well documented and the lowest possible doses often recommended in order to minimize such effects (von Knorring, 1992), the prevailing psychiatric view is that the benefits for the psychotic patient undergoing neuroleptic treatment are greater than the disadvantages (Hedaya, 1996).
This therapeutic optimism contrasts with the consumer's more critical perspective. In autobiographical reports and interviews with patients or former patients treated with neuroleptics, the focus is often not only on the externally observable effects and side-effects, but also on the subjective suffering that is difficult for patients to communicate to others (Barnes & Berke, 1971; Vonnegut, 1975; Molin, 1992). Typical formulations in these reports are that the medication makes one feel "confined in a glass jar", that one is no longer the master of one’s personality and emotions, and that psychiatric staff and other bystanders frequently do not realize that the medication has such aversive consequences.
In an extensive Nordic study, Lingjaerde, Ahlfors, Bech, Dencker, and Elgen (1987) acknowledged the difficulties in assessing the subjective side effects of psychotropic drugs and the discrepancy between evaluations by patients and doctors. Compared to patients, the doctors tended to underestimate gross reactions; with lesser effects the relationship was reversed. For example, doctors took note of mild signs of tardive dyskinesia more often than patients did. Van Putten (1974) categorized patients as either dysphoric or syntonic responders. Whereas the syntonic responders reacted to their treatment with a low-potency neuroleptic drug (thiothixene) with comments such as "I don’t feel threatened any more" or "it brings my mind into focus" (p. 189), the dysphoric responders lost their ability to think straight and felt wronged by the treatment. Later they would refuse to try any antipsychotic drug whatsoever (cf., also, Van Putten, May, Marder & Wittman, 1981). Weiden et al. (1989) confirmed the correlation between early dysphoric reactions and later noncompliance in patients who were treated with haloperidol. Following Strauss (1989), Awad (1993) noted that the patient’s personal experience is usually not addressed in research on neuroleptic treatment. He emphasized that the patient’s altered subjective state depends on an interaction of pharmacokinetics and a host of psychosocial factors such as demographics, character traits, extrapyrimidal side-effects, depressive reactions, and attitudes towards health and sickness.
In an article on neuroleptic dysphoria, Emerich and Sanberg (1991) wrote that, even though it is true that they have brought relief to patients suffering from schizophrenia and other disorders, haloperidol and other neuroleptics also cause sedation and extrapyrimidal symptoms, catalepsy, weight gain, depression, anxiety attacks, and cognitive blunting. This statement was substantiated by remarks by Bignami (1991) on experimentally induced neuroleptic dysphoria in animals, and by Harrow, Fichtner, Grossman, Yonan, and Sand (1991) on unrecognized depression among schizophrenic patients treated with neuroleptics. It also prompted Hollister (1992) to acknowledge that the adverse affects of psychotropic drugs are well known, and to reiterate the hypothesis that the more disturbed a patient is, the better will he or she tolerate neuroleptics. Hollister wrote that "One must be crazy, either literally or figuratively", to take these drugs (p. 531).
In experiments in which researchers have tested relatively low doses of haloperidol on themselves (Belmaker & Wald, 1977; Kendler, 1976), the results point in the same direction: the investigator-subjects experienced anxiety, loss of motoric control, and a cognitive, emotional, and volitional blocking, that is, what in psychoanalytic terms would be described as a loss of ego functions. However, in a randomized treatment study with healthy subjects (Di Mascio et al., 1963a, 1963b), the results were different: whereas single doses with varying strengths of chlorpromazine produced sedation, disturbances in autonomic functioning, psychomotoric and cognitive impairment, and a tendency towards social withdrawal, the corresponding doses of perphenazine and trifluoperazine led to mild psychic stimulation and to higher speed in carrying out cognitive tasks. Similarly King and Henry (1992) observed improved reaction times in normal subjects who were given an experimental dose (1 mg) of haloperidol.
Psychoanalysis provides a method for studying conscious and unconscious aspects of subjective experience, and a theory of their foundations in the body. Yet, psychoanalytic studies on pharmacological treatment of mental disorders are scarce. Azima (1959) and Ostow (1962) speculated that neuroleptic drugs modify the strength of psychic energies, primarily aggression. Using psychoanalytic theory in a more consistently psychological way, Sarwer-Foner (1957, 1963) emphasized that the physiological influences of neuroleptic drugs interact with factors such as the patient's personal resources (ego strength that may exist aside from the fact that a patient is psychotic), the patient’s self-image, the treatment milieu, and the relationship between patient and doctor. A pharmacologically induced inhibition to carry out impulses may be experienced by one individual as a support of his capacity to control himself, whereas another person might experience the same pharmacological influence as a loss of the capacity to act forcefully or as a castration.
Countertransference in connection with neuroleptic treatment was illustrated by the not untypical situation in which a physician, who was afraid of or disliked a patient, felt that he at least gave the patient something by administering a drug. In such situations, Sarwer-Foner wrote (1963), the drug is used to minimize the doctor's contact with the patient, and the patient may accurately interpret the treatment as a sign of the doctor's neglect or fear. This may contribute to experiencing the drug as "bad" or "poisonous" (p. 227). Nevins (1990) elaborated on Sarwer-Foner’s multifactorial model of how the medication is experienced and, referring to Winnicott (1956) and Hausner (1985), emphasized the medication’s function as a "transitional object" and a psychological source of safety.
The aim of this study is to explore how psychiatric patients consciously and unconsciously experience their treatment with high-potency, low-dose neuroleptics. The study aspires to capture individual experiences as well as patterns of experience within and between the participating subgroups of consumers of neuroleptics in a fashion that is true to the complexity of subjectivity.
Three groups of psychiatric patients — patients with recent onset and a short experience of being treated with neuroleptics, chronic patients with extensive neuroleptic experience, and "veterans" who had used neuroleptics in the past and discontinued their pharmacological treatment — were interviewed by one of two interviewers. Both interviewers were psychoanalysts with extensive psychiatric experience, one with basic training as a clinical psychologist, the other as psychiatrist. Each interviewer met half of the participants in each group.
The participants were interviewed three times within a period of two to four weeks. The sessions, which lasted 30-60 minutes depending on the subject's capacity to sustain a dialogue, were audiotaped and summarized in two-to-three-page briefs. These summaries covered the participant’s background, character, diagnosis, transference-countertransference phenomena in the interviews, drugs and doses used currently and in the past, and the conscious and inferred unconscious experience of the pharmacological treatment.
In order to identify possible biases that might influence the descriptions of the participants' experiences, the interviewers scrutinized each other's summaries. Curiously, the psychologist tended to formulate questions about unknown somatopsychic mechanisms more often than did the psychiatrist. Aside from this, no systematic differences were found between the two sets of reports. However, one recurring (transference-related) tendency noted by both interviewers was that several participants initially appeared to criticize the medication, because they believed that this was what their interviewer desired.
Group 1 (recent-onset patients) and Group 2 (chronic patients) were recruited through a psychiatric service in a suburb of Stockholm and Group 3 (veterans) through a national patient organization. The participants in the recent-onset group were younger than those in the other groups (Md=21 vs. 42 and 47). The recent-onset patients in Group 1 came from the upper middle class, whereas the participants in the chronic and veteran groups came from middle, lower-middle, or working class backgrounds.
As the neuroleptic medication was frequently combined with other antipsychotic, antidepressant, and antianxiety drugs, an initial ambition was abandoned to recruit individuals who used classical low-dose neuroleptics only. The participants' diagnoses and medication are listed in Table 1.
Subjects, ages, gender, diagnoses and known psychotropic medication (within brackets)
A, 31 (f):
F, 32 (f):
M, 53 (m):
B, 19 (f):
G, 46 (f):
N, 45 (f):
C, 33 (m):
H, 47 (m):
Explosive psychotic disorder
O, 55 (m):
Affective disorder with psychotic episode
D, 21 (f):
Psychotic mood disorder
J, 42 (m):
P, 38 (m):
E, 22 (f): Psychotic disorder
K, 25(f): Delusional
Q, 41 (m):
L, 42 (m):
Schizophreniform disorder (chlorpromazine, clozapine, haloperidol, perphenazine, thioridazine, zuklopenthixol)
Group 1: The recent-onset group.
The one male and four female participants in the recent-onset group were aged 19 to 33. None was manifestly psychotic at the time of the interviews. However, all participants in this group were anxious and inhibited. They seemed frightened by having recently experienced psychosis and confronted psychiatry for the first time in their lives, and they resented being exposed to yet another psychiatric professional. About 50% of the approached individuals with short periods of neuroleptic treatment declined to be interviewed. The five who eventually consented to take part in the study had used neuroleptics for between 3 and 10 months (Md=0.5 yrs).
Group 2: The chronic group.
The three women and three men in the chronic group were aged 25 to 47. They appeared to be more severely disturbed than the participants in Group 1. Two chronic-group participants showed signs of psychosis during the interviews. All were heavily sedated and had difficulty in articulating feelings and thoughts. The length of their ongoing neuroleptic treatment varied between 7 and 21 years (Md=13.5 yrs).
Group 3: The veteran group.
The constrictedness of the participants in the recent-onset group and the sedation of those in the chronic group at first seemed to make the study impossible. The solution was to recruit a third group: veteran patients who had discontinued their treatment with neuroleptics. These participants were expected to be neither acutely anxious nor affected by ongoing pharmacological treatment.
The four male and one female psychiatric veterans in Group 3 were 38 to 53 years old, that is, slightly older than the members of Group 2. The length of time they had been treated with neuroleptics prior to terminating medication ranged between 2 and 24 years (Md=10.4 yrs). The individual constellations of time with and without neuroleptics among the veterans were the following (the first figure represents years with and the figure in parantheses subsequent years without neuroleptic drugs): 2(18), 2(23), 11(0.4), 13(6), 24(0.8). A sixth person in the original veteran subsample withdrew her consent to use her material out of fear that it might be used against her.
Typical experiences in the three groups
The following excerpt fron the interviews with B illustrates the constrictedness that was typical in the recent-onset group. It also shows the importance the medication had as a source of safety for this young woman.
B, a 19 year old high-school student, treated with perphenazine for six months (dose unknown), at first had nothing to say. She felt empty of thought and emotion but wanted to cooperate with those on whom she depended to get well, which she believed included the interviewer. B was happy that she would soon be lowering her dose, even though she did not experience any unwelcomed side-effects. Her wish to be normal was a central issue for her, and she considered her medication helpful in this regard. It improved her self-control and made it possible for her to visit home and school in a "normal-enough" condition.
Even though participants in the chronic group were eager to share their suffering with the interviewers, their thought and speech were blunted, ostensibly by the medication. The following summary was written after repeated listening to the tapes with G, a 46 year-old woman who suffered from a schizoaffective disorder and who was treated with neuroleptics for more than 20 years. The material underscores the interaction between the primary disorder, the direct biochemical effects of the drug, and its symbolic meanings. G perceived her medication as something good — again, a source of safety — as well as a source of evil.
G’s daily medication consisted of 12 mg of perphenazine, 75 mg of propiomazine, an unknown dose of levopromazine, and an anticholinergic drug. G also drank a moderate quantity of beer every day. Not surprisingly, she was dulled. G’s ways were far removed from her ideals about how to lead her life, and she felt bereft of the power to do anything about it. She was convinced that the medication had put an end to her sexual interest She was torn between being open to her sexuality and her anger, the latter which at times "drove her crazy", and accepting being overmedicated, which was psychologically impoverishing. A residue of G's libidinal self was reflected in positive feelings towards the interviewer that were discernible through her drowsiness only on repeated listening to the tapes. The interviewer asked himself: How would G's desire for contact appear, were she not medicated? Hidden behind chaos and psychotic splitting? Subdued behind defensive bluntness? Did G gain more than she lost by being medicated?
Although the veterans, as expected, were neither acutely anxious nor sedated, they too introduced a threat to the study. Two out of five in the veteran group proved to be not former but in effect chronic consumers of neuroleptics. Thus the veteran participant with three months (0.4 yrs) without medication went back to taking perphanizine at the time of the interviews out of fear of becoming psychotic again. A second, highly articulate participant, N, who had struggled for ten months to maintain her balance without medication, became psychotic, was confined to a hospital, and resumed treatment with neuroleptics shortly after the interviews. At an early stage of recruitment — before the withdrawal dilemma among long-times users of neuroleptics was seen as a finding — a third such person was excluded from the sample.
The dilemma of neuroleptic withdrawal
After years of medication, patients become habituated to their treatment. The vulnerability to psychosis when off medication appears to increase with the time that medication has been used, also for physiological reasons (Gilbert, Harris, McAdams, & Jeste, 1995; Ventura, Neuchterlein, Pedersen-Hardesty, & Gitlin, 1992).
For the experienced subjects in Groups 2 and 3, yielding to the need for the drug had a subjective quality of resignation or "identification with the aggressor" (A. Freud, 1937/1966). Participants in these groups consistently stated that the medication made them sick in a new way. Yet most of them continued to take it.
Treatment compliance and masochisism
The pervasive ambivalence towards the medication suggests that the term compliance is an euphemism in this context (cf. Baldessarini, 1994). L, a psychiatric patient since 22 years, who seemed to derive gratification from hardship, was one of many participants who evoked questions about self-destructiveness and masochism as factors behind treatment compliance. Masochism, here, refers both to deriving pleasure from pain and to Freud's (1924/1961) additional use of the term to denote a primary self-destructive drive that has become eroticized.
L said that he initially accepted taking chlorpromazine, since it was prescribed by a doctor. However, the treatment gave him cramps and made him feel sick to his core. The psychiatrist maintained that it was L’s mental illness and not the medication that produced these symptoms. This mind-splitting situation culminated in a suicide attempt by jumping from the fourth floor, after which L was injected with perphenazine and haloperidol while in intensive care. L earnestly believes that the treatment made him more psychotic. Having survived the jump, he thought he must be Jesus. L has recently been promised clozapine. He hopes that the new medication will finally cure him, even though he is highly critical of drugs in general and would never recommend any type of neuroleptics to anyone. He says that he would rather recommend psychotherapy, momentarily disregarding an earlier remark that psychotherapy has never done him any good (which the interviewer understood as a critical comment to his being a psychoanalyst). The way L humbles himself when he meets a doctor on his way out from one of the interviews adds to the impression that his subservience is a method of coping with humiliation and rage.
One could, perhaps, claim that L and other psychiatric patients merely submit to a therapy that is aggressive by design (analogous to a patient accepting a forceful treatment of a severe somatic illness, for example, chemotherapy against cancer). This would seem to be borne out by the fact that the younger, recent-onset participants felt strengthened by their medication and supported by their psychiatrists. The long-term consumers, too, accepted their treatment, but not without bitterly deploring its side effects. At least one chronic-group participant, the 25 year-old K, who had used varying combinations of thioridazine, levopromazine, and haloperiodol since age 17, consciously welcomed the numbing effects of her treatment, even though it made her heavy in every sense of the word — she weighed 115 kilos. Without medication K had nightmares, and became frantic with fantasies about sexual abuse when alone with a man.
Other forms of erotization.
There were many examples of the medication allying itself with eroticized — sexual or antisexual — treatment relationships. (I am not in a position to know in which instances the treaters were aware of this.) The following excerpts also illustrate how erotization was repeated in the interviews.
A vacillated between self-assertion and submission in many of her relationships. At first she was reluctant to be interviewed at all, but changed her mind after the first interview. On her own initiative she stopped taking her medication, 200 mg of thioridazine, in order, she said, to experience more intense sexual feelings and share these with her interviewer at their next meeting. Her excitement seemed to replicate aspects of a highly meaningful, sexually charged, but in the end unmanageable relationship she had experienced with a doctor. In the first interview, A said that she appreciated that her medication stopped her from masturbating.
Similarly, M, a manic-depressive and episodically psychotic veteran participant who had used neuroleptics for 13 years and managed without it for 6 years, was stimulated by being interviewed and by his role as expert witness. Quite aggressively he said again and again that he liked the interviewer and that he considered his interest kindhearted. The interviewer found it difficult to end the interviews with M in the stipulated time without feeling harsh. Sensing M's excitement, he was concerned that M might become manic and lose control over himself. M told the following episode:
After a conflict on a ward, I was once injected with haloperidol to the point of getting convulsions. I pleaded that they would let a female nurse give me the injections and that I should get half of the prescribed dose in each buttock. I believed that this would lead to a more even distribution of the poison in my body. They did not do as I asked.
It seemed to the interviewer that M's request was also meant to mitigate his panic of being homosexually abused.
Punishment with drugs.
Even though psychiatry continues to be compromised by what looks as acted-out countertransference hatred of patients, one cannot escape the fact that the patient with a psychotic personality, because of anxiety about intimacy, often rejects the good-willed approaches of others. Inevitably we, the others, will feel angered by these rejections (cf. Winnicott, 1949). So, it was no surprise that many participants, like L and M, had experienced being punished with medication.
Another example was provided by N who in a state of acute confusion about who she was, once insisted on lying in another patient's bed and refused to leave it in order to "be" that patient. The psychiatric personnel responded by forcefully injecting N with haloperidol. Their conscious intent was probably simply to stop her psychotic behavior. N perceived the injections as an assault.
Whether submissiveness is understood as enacted "primary masochism" or as a response to external violence or coercion, it is always close to anger. Further, anxiety over aggression — one's own or that of others — is a well-documented theme in the psychology of psychosis (cf., e.g., Frosh, 1983; Klein, 1946/1977; Little, 1990; Pao, 1979; Vaughn & Leff, 1976).
Even though the participants generally felt that their medication stopped them from acting on angry impulses, many complained that their angry feelings and fantasies remained unaffected by the pharmacological treatment. For example, N (who wanted to be another patient), had been treated first with thioridazine and then with depot injections of fluphenazine, haloperidol, and zuklopenthixol for 20 years. At the time of the interviews, she had been off medication for 10 months. She desperately wanted to live without neuroleptic drugs, for she believed that they took away her capacity for love and did not change the terrifying "Oberstürmdevils", which was how she experienced certain people at her workplace.
N was aware that she demonized people. Nonetheless they remained both hated and persecuting, even when N took her medicine. In all of her dealings, Nexperienced severe moral anxiety. Her guilt feelings were reflected in a wish to fight cruelty in society, engagement as a voluntary social worker, and in her poetry. But her methods of accomplishing her aspirations were sadly breaking down before our eyes. She wanted to go to a hospital without being medicated and was disappointed that her psychiatrist would not hear of this. In her third interview, N became anxious over having criticized the psychiatrist and said that it probably is impossible to free oneself from psychosis without medication. Three weeks later, she called me [her interviewer wrote] from a hospital, acutely psychotic and, it seemed, still affected by the positive transference that had evolved in the interviews. She begged me to instruct the doctor to discontinue the medication and to tell him that she was pregnant, which may also have meant that N felt doubly vulnerable to the toxic effects of her treatment.
Other participants, too, described how their medication stopped them from acting crazy without affecting their underlying anger and fears. The intractable rift between an angry and frightened inner self and a well-behaved external self was felt by some to make the treatment meaningless. A last observation related to the combination of "free-floating anger" and meaninglessness (as well as to self-destructiveness) was that participants in all groups reported suicide fantasies or attempts.
Differences between diagnostic subgroups
It has been suggested that patients who are able to end neuroleptic treatment may have a primary affective disorder rather than a psychotic one. This seems to be borne out by the two veteran participants, M and O who, in addition to Q, who had never been psychotic, were the only participants who had been able to relinquish their medication permanently. But it was also clear that all participants were sad, which speaks for the possibility of depressive affect being a side-effect of neuroleptic treatment (Harrow et al., 1991).
The accounts of M, O, and Q of how the medication worked differed only in emphasis from what more psychotic participants described. Again, the primary effect was the blocking of cognitive and emotional functioning. Unsure of whether it was the illness or the medication that caused it, O, for example, told how music that he normally considered wonderful — symphonies by Mozart and Sibelius — sounded disunited and tortuous, like "plinkety-plunk bits and pieces", when he was on medication. He recalled that the medicine (chlorpromazine, haloperidol, perphenazine) made him sluggish and indifferent to his own condition. The treatment led to severe akathisia, which was particularly painful in light of the gratification he normally found in physical work, and it made him extremely dependent on others. Owas given the medication after a personal crisis that led to explosive outbursts of anger. He remembers his regression and submission after taking his medication as a humiliating experience. Only after stopping taking the drugs with the help of a psychiatrist who took his complaints about side-effects seriously, was O able to recover his faculties and joy of life.
The participants generally acknowledged that the medication diminished delusional symptoms and helped them control psychotic acting out. Yet anger and projected angry fantasies frequently remained active as sources of anxiety unaffected by the treatment. All long-term users deplored the muscular side-effects and the disturbed ability to concentrate and coordinate thought and emotion caused by the medication.
Participants in the recent-onset group were more favorable to their medication than were the long-time consumers. This probably reflected shorter treatment periods as well as a comparatively cautious attitude towards medication among their psychiatrists. The younger participants tended to see the antilibidinal effects of thioridazine, a high-dose neuroleptic drug, as a support.
Other participants, too, sometimes welcomed the accumulated impact of different psychotropic drugs as an aid to self-numbing, even though they also believed that the medication interfered negatively with their love life. It was hard to differentiate the direct effects of the treatment on sexuality from the participants' projections of inner conflicts onto the medication. Further, as with aggression, eroticized aspects of how the medication was experienced were condensed with qualities of the treatment relationships. The firmest observation with regard to love was that in no case did the neuroleptic medication strengthen the individual's ability to love (or hate) without fearing immense harm.
From a psychological point of view, treatment with classical neuroleptics, as a socially sanctioned external agent for attacking one's own mind, may join forces with the psychotic patient's propensisty for unconscious self-harassment and with the self-destructive function of the psychotic breakdown (cf., e.g., Bion, 1959; Searles, 1965; Pao, 1974). Submitting to the treatment with high doses of neuroleptics may thus be a relief from shame over self-destructiveness and rage, and from helplessness in being overpowered by such forces. One may consider the treatment not only as a way of getting well by getting sick — this is an archaic, irrational dimension of many approaches in psychiatry — but as assisted spiritual suicide.
Neuroleptics and suicidality
The combination of anger, anguish that this anger feeds into, loneliness, humiliation of being emotionally knocked out by the medication, and the insolvable dilemma of continuing or discontinuing the treatment, may amount to a suicidal situation. Stefenson and Cullberg (1995) arrived at a similar hypothesis, namely, that the long-term existential burden of psychosis and its treatment is a critical factor behind the suicides of schizophrenic individuals.
Statistics substantiate that the problem of suicidality among psychiatric patients in the neuroleptic era is a real one. Registered suicides among psychiatric in-patients in Sweden rose from 50 cases (app. 4% of all known suicides) in 1950 to more than 200 cases (app. 12%) in 1979 (Swedish Board on Welfare and Health, 1985). Alnaes (1990) reported a more than four-fold increase of the suicide rate in one mental hospital in Norway between 1959 and 1988. Ösby, Nestor, Brandt, Ekbom, and Sparén (2000) reported an almost two-fold increase of completed suicide among schizophrenic patients in Stockholm from 1976 to 1995. There are many conceivable explanations of rising suicide rates among psychiatric patients, the reduction of hospital beds being one (Ösby et al., 2000). A thorough analysis of this trend should, however, also consider the role played by antipsychotic medication. This applies, even if the medication used in contemporary psychiatry is another type of drug than classical neuroleptics.
Methodological problems in applied psychoanalytic research
Organizing complex experience under distinct headings (anger, sexuality, acceptance, submission, etc.) may mean imposing order where it does not really exist. Simplification, however, is inescapable in systematic psychological studies. When unconscious aspects of the patient experience are added, questions about the validity of a psychological narrative become more challenging. My view is that unconscious phenomena, for example, primary masochism, are so fundamental as to be generalizable, at least to subgroups of the population of consumers of neuroleptics. The validity of the formulations on the role unconscious self-destructiveness in the ways of the psychotic individual can be assessed by gauging their clinical relevance and the coherence with which they are linked both to the emprical material at hand and to theory.
But how does one know that inferred unconscious experience is not a mere extension of the observer's fantasies? Here, such inferences were supported by observations of transference and countertransference in the interviews. Beyond self-analysis, this meant relistening to the tapes (an addition to the standard psychoanalytic procedure) and letting the two interviewers scrutinize each other's conclusions. Possible countertransference colorings of the interviewers' reports, for example, identification with patients perceived as victims, and unconscious exploitation of narcissistic and suicidal individuals as suitable targets for externalization of one's own similar, if milder, traits (cf. Volkan, 1986), were discussed in a separate article (Titelman, 1999).
A last methodological point concerns the selection of participants. In order to optimize the generation of hypotheses, the groups were deliberately heterogeneous within the framework of having been treated with neuroleptics during the stipulated time periods. Yet, the large rejection rate among the approached patients with recent onset made Group 1 homogeneous; the participants were all shy and "constricted". Telephone conversations with the rejectors indicated that they were more acutely psychotic than the participing recent-onset patients. Had they been interviewed, the rejectors' apparent confusion may have added to the initial problems of the study. The veteran group, too, was selected in an unplanned way. These participants were activists in a patient organization whose ideology is strongly against routine precription of psychotropic drugs, which may have strengthened their critical views of the medication.
Future research and concluding remark
The role of self-destructiveness and aggression in psychosis, not the least the patient's inablitity to cope with anger, and the countertransference reactions such tendencies provoke in the helper, merits continued attention in the clinical setting as well as in future research. One extension of this study might be to look into what treatment with neuroleptic drugs means to the psychiatrist.
Another topic to consider in the future is the patient's subjective experience of the new, atypical neuroleptic drugs. Every promise of a cure of psychosis and schizophrenia is received with great expectations in the psychiatric community as well as in society at large. As used to be the case with classical neuroleptics, there is now a steady stream of reports about beneficial effects of the atypical neuroleptics, including decreased sucidality among schizoprenic patients (Meltzer & Ghadeer, 1995). Yet, there remains a risk for emotion to misguide psychiatric practises. Difficult-to-contain transference and countertransference are powerful factors that influence whoever interacts with severely ill psychiatric patients. There is also a risk of commercially motivated exaggerations with regard to the efficacy of new kinds antipsychotic therapies, pharmacological or other.
The destructiveness of psychosis is a form of hell on earth that calls for an open mind about new anti-psychotic treatments. Nonetheless, a sound skepticism with regard to psychiatric innovations is to remember what is both clinically known and demonstrated in this study: To the psychotic person, who is "nothing" or as in pieces and who vainly tries to restore his or her self by being something fantastic, for example, God or Jesus, the patient identity and the "neuroleptic state of mind" may be compelling for internal reasons, however destructive and undignified they also are.
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