Perhaps the strange and bizarre behavior is not meaningless. Perhaps its origins are not so different from the origins of our own inordinately logical and comprehensible strategies for living and surviving. Perhaps these awesome symptoms are the product of the developmental process gone awry.
Most of us have experienced "near psychotic-like" symptoms in our dreams. Dreams are governed by a different logic than is our waking life and in dreams "anything can happen" and often does. People who are dead live again. Wishing something can make it come true. Calamities can be undone with a fanciful thought. We can be hero or victim depending on whatever issue we are working on in our dream work.
The loss of reality testing means the loss of the shared world and with it the loss of meaningful communication with others. If a person's perceptions are so different that they become "unreal" to us, we stop being able to understand what is being said. If a person assigns meanings to a word that bear no similarity to the meanings we assign, then the same words may be used but no meaning is exchanged. The disturbed person becomes isolated because he no longer experiences or understands the world in the way that we do.
As bizarre as hallucinations and delusions may seem, they are the attempts of a beleaguered personality to survive, to stay alive. Often the original hallucinations or delusions are of a kinder, more accepting reality than the one in which the person lives. They seem to represent an escape from a harsh and brutal reality that resists amelioration. All too often, however, the sanctuary afforded by the original delusions and hallucinations is transformed by the unresolved conflicts and become even more cruel than the reality they sought to soften.
For our purposes, we are going to look at psychological explanations that are rooted in the developmental process. There seems an inherent logic in viewing the psychotic symptoms as failures to negotiate certain developmental tasks that form the building blocks for later, more sophisticated personality development. Psychological and physiological development moves from the dependent, primitive, undifferentiated, need-driven to the autonomous, stable, multi-functioning, reality oriented functioning associated with the mature organism. Physiological development is a process of unfolding guided by an internal, genetically set biological clock. Nerves become myelinated, fontanel close, hormones are released, muscles become capable of control, bones grow, secondary sex characteristics emerge. If all goes well, the newborn grows from infancy to adulthood along a predetermined path. Psychologically, however, there can be great developmental variation. No precise genetic clock governs this growth. While there is an important interaction between a growing organism's physiological readiness and his/her psychological environment, the effects of this environment are impressively influential in the outcome of the maturing process. A psychologically damaging environment can undo the best genetic stock leading to a disturbed, non-functional personality residing within a sound body.
Some theorists propose that the origins of the psychosis are found in the first year of life. Something goes profoundly wrong in the relationship between the parenting figure and the newborn child. The theory suggests that the damage is so critical that future developmental steps will suffer a distorted outcome or not be taken at all. There is also the conviction that the earlier the trauma occurs in an individual's life, the more difficult it is to overcome. Some believe that early emotional trauma--the kind that leads to psychosis--is actually irreversible. Needless to say, there is controversy not only on the origins of the psychosis but also about methods of treatment and ultimate prognosis.
The cornerstones of development are important to understand because they provide a way of viewing psychotic symptoms.
Disturbances in basic trust are reflected in difficulties with separation, desperate clinging, a point of view that no one can be trusted, the conviction that "out of sight always means out of mind," a refusal to attach because any separation invokes the primitive fear of inevitable abandonment. In the severely disturbed, paranoid symptoms and inordinate dependency often indicate that basic trust has been profoundly disturbed.
Disturbances in object constancy and basic trust lead to profound and enduring psychological disturbances. All future personality development is rooted in these primary building blocks. Thus, if the foundation is weak, all subsequent structures are subject to collapse when the individual experiences high internal or external stress.
The human infant, for all his/her seeming fragility, can be an amazingly resilient creature. If this were not so, the number of people expressing high degrees of psychological disturbance would be even greater than it is. It is ofttimes quite amazing what the human is capable of enduring and still turning out within normal limits. Our skill in understanding psychopathology is, unfortunately, better postdictively than it is predictively. Looking back on an individual's history, it is often quite easy to point out the events that had a traumatic effect on personality. It is much more difficult to estimate the impact of an event while its happening. Psychology is an imprecise science, but we have begun to cast a systematic eye at the process of human development and the events that affect it both positively and negatively.
The first year of life is critically important in the genesis of psychosis. The developmental tasks of establishing body boundaries, basic trust, and object constancy must be begun. The interactions between parent and child must foster and nurture a healthy completion of these tasks in the months and years to come. Successful parenting involves the ability of the caretaker to suspend his/her needs in favor of the infant's needs. While it is difficult to imagine or comprehend the infant's internal experience of the world, it is nevertheless important to make some inferences about what it could be like. Unfettered by reality or its limitations, it is possible to imagine that an infant is a mixture of grandiosity and helplessness. The hungry infant who cries to signal his internal discomfort may well imagine in the most primitive and wordless way that his cries brings the satisfying breast or bottle into existence to meet his/her hunger. The parent who responds predictably and consistently to the child's needs initially fosters this mistaken belief of grandiosity. The child creates his world on the basis of his/her limited experience; s/he simply knows no better. At some very basic, primitive level, good parenting conveys to the child that his efforts, limited as they may be, make some difference in the world. Consistent caring from parents who can put the child's needs first communicate that the world is nurturing, comforting, trustable, and non-abandoning. These are powerful messages encoded in the memory of the child prior to the existence of words. During the first year of life, the infant needs to believe that "the world is his/her oyster." Socialization can wait. Civilization will have its turn, but first, needs must be met with little frustration. During the first year of life, there is little need to be concerned with "spoiling the child."
As the child matures physiologically and psychologically, reality will impinge. The Nirvana like existence of the first year is replaced, appropriately so, with the requirement to master other developmental tasks. For the growing child, there is a never ending series of jobs to do, skills to master in order to fit into the society in which s/he lives. Mastery is accompanied by hard work, delays, substitute gratifications, failures and frustration. The well-indulged infant is at no risk of becoming the self-indulgent adult if the developmental process moves along its normal course. While the successful negotiations of infancy will most likely preclude the development of a psychosis, it should be remembered that it is not an insurance policy against all forms of emotional disturbances that may find their origins in later periods of development.
Recent theoretical thinking has deemphasized the transitional view of the borderline. Instead, the borderline personality is thought to occupy a place on the pathology continuum, less disturbed than the psychosis but closer to that level of disturbance than to other emotional disorders. It presumes some mastery, although not altogether successful, of the developmental tasks previously outlined. The primary emotional conflict seems centered on primitive rage and the failure to form a core identity. The rage seems the response to excessively frustrating, depriving interactions with the primary caretakers very early in life. While the environmental deprivations were severe, they were not sufficient to evoke a psychotic orientation. In reviewing the history of a borderline, it is not surprising to discover that there was one parent or a grandparent or some surrogate who tempered and mitigated the otherwise traumatic parenting experienced by the child.
Borderlines often present themselves as depressed, feeling dead or lifeless inside, empty, energyless, goaless. They are not dysfunctional in the sense of being unable to hold down a job or even enter into a stable, long term relationship. It is the lack of zest, the lifelessness of these people that suggest the severity of their disturbance. They appear marginal; peripheral to life. While not psychotic, they may often have periods when they behave, think, and experience the world psychotically. They are often highly suicidal and, in the course of psychotherapy, it is not unusual for them to become actively suicidal and require hospitalization. People who work therapeutically with borderline patients often report feeling anxious and uneasy with these people. It is as if the borderline nonverbally communicates the severity of the underlying disturbance before it becomes overtly apparent. The experience of this anxiety in the professional helper remains one of the best clinical indicators that there is more going on than meets the eye.
Psychological health requires a consolidation and an integration of disparate, often contradictory aspects of who we are. The "I" that we take for granted is the result of an Herculean effort to bring together a relatively consistent picture of our "self." The opposite of integration is "splitting," a disowning of parts of the self that do not fit into a coherent picture. The borderline has particular difficulty dealing with these inherent contradictions and is prone to split off pieces of the self rather than attempt to integrate them. Often, it is the primitive rage that is disowned. It is feared that its eruption will be overwhelmingly destructive or be so unacceptable that it will eventuate in the loss of all relationships. It may be repressed or it may be projected onto the others or the environment. In the process of therapy, the borderline patient must own this rage, confront his fears surrounding its power, develop structures for managing it, and, inevitably, fit it into his conception of "self." In the most simple, reductionistic terms: "Even nice guys get angry."
The treatment of the borderline is difficult, time consuming, and uncertain. There will be periods in treatment when the borderline functioning is replaced by psychotic behavior and thinking due to the stress involved in integrating various aspects of the self. It is during these psychotic periods that the hotline may be called.
If it seems to you the feelings are at fever pitch, do not ask the caller to tell you more about them. Instead, use calming interventions. Use a calm but firm voice that indicates both caring and certainty as you speak.
"I know you are very upset. Lets take a few moments for you to calm down so we can talk. Try taking a couple of slow, deep breaths."
"I want you to tell me about this in detail." Ask questions designed to organize the person's story and deal with only small bits of it at a time. "How did it begin? " "What were you doing at the time?" "What happened next?" "And then..." Your technique is designed to slow the person down and to break experience into manageable chunks. Feelings are acknowledged but are not made the main focus of the conversation.
If a caller is hallucinatory or delusional and asks if you "hear" or "see" what he/she is experiencing, respond directly with a "no." Little is ever served by entering the delusional world. It can be very difficult to extricate yourself at a later point.
When appropriate, find out about the medications the caller is using. Find out if he/she has been taking them on the schedule recommended by the physician. If the caller has discontinued use of his/her medications without consulting his/her physician, encourage the caller to contact the prescribing physician to discuss the management of the medication.
DO NOT ALLOW YOURSELF TO GIVE MEDICAL ADVICE OR MEDICAL INFORMATION.
We are not physicians and questions or concerns of a medical nature should be referred to the appropriate professional. Acknowledge the importance of the questions and the importance of getting the right answers from a qualified professional. Become familiar with the Physicians Desk Reference (PDR) and the major tranquilizers and anti-depressants that are prescribed as anti-psychotic medications. Check out the side effects so that you recognize them when your hear them. Knowing them, will help you to know when to actively refer the caller back to his/her prescribing physician.
Keep your expectations about what you're going to accomplish in this call realistic. You are not going to cure a psychosis in 20 minutes. Essentially, you are going to try to help someone through a period of high anxiety. You are buying time with the caller. Your interventions should be concrete, pragmatic, problem solving. A person overwhelmed by anxiety and terror is not likely to have the resources to do his/her own problem solving. You will need to lend your skills and resourcefulness to the caller during this period of time. Thus, you may make direct suggestions, offer plans for dealing with the crisis of the moment, caution or urge a person to not do something, and, at times, actively encourage the person to seek hospitalization.
Do not be surprised if these calls make you feel confused and very often helpless. You are attempting to enter the world of a person whose frame of reference is quite different from your own. Your own ego prevents you from understanding the disturbed world of the psychotic individual as a protection and a safeguard. Working with people who are very disturbed is an incredibly exhausting and draining process. It is not meant for everyone and knowing about your own limits regarding these kinds of disturbances is very important.
Maintaining professional distance is important. The anxiety of the psychotic or borderline can be contagious and disabling. Their stories are tragic, their pain palpable, and their anxiety intolerable. The very disturbed caller can create a vortex about him/herself that seemingly sucks everything into its chaotic midst. If you begin to feel as confused, overwhelmed, and helpless as the caller, something has happened to your distance; you have been engulfed by the caller's world and can feel temporarily as unable to cope as he or she does. While this certainly represents a high degree of empathy, it is not helpful to the caller or yourself. No one is exempt from this happening. Experience provides a safeguard but it is not an absolute guarantee that you will never be contaged by the disturbed caller's intense emotional aura. Constant self-monitoring is required. Supervision is an excellent means for maintaining or restoring perspective.
It cannot be overemphasized that working with highly disturbed individuals is fertile ground for intense personal reactions on the part of the helper. It is as if the highly disturbed have a special sensitivity to the vulnerabilities of others and can effortlessly plug into those vulnerabilities. Strong reactions to or about these callers (positive or negative) should alert a crisis worker to the need to explore these reactions with a supervisor.
Dealing with people who are psychotic or borderline is amongst the most difficult and challenging tasks a clinician performs. While it is gratifying to imagine remarkable cures and the return to full functioning, we also need to learn to be satisfied knowing that we may have kept a person from another hospitalization or helped in a way that allowed the person to go to his/her job the next day. There are seldom "heroic rescues" in this particular aspect of crisis work. The disturbances are profound and only a select few who are able to avail themselves of costly, intense treatment facilities will experience a recovery that places them within the normal range. The severely disturbed often live a marginal life. Medications have made it possible for people who would have heretofore spent the majority of their lives institutionalized, to live, work, and maintain a family in the outside world. As we continue to learn more about the infant science of psychology, the hope is that our methods of helping will provide the potential for markedly improved functioning for all who seek our services.
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