Abstract
The purpose of this case report is to demonstrate the way in which spirituality can function as an essential pathway to foster attachment in psychotherapy. The author details a yearlong psychotherapy treatment with a chronically and persistently mentally ill lesbian woman diagnosed with a traumatically induced schizophrenia in a state psychiatric hospital in New York City. The case not only details the use of relational model of psychotherapy, but also illustrates how the active integration of spirituality is an essential component to the relational psychotherapy treatment.
Keywords: Psychotherapy, Attachment, Spirituality, LGBT, Schizophrenia
Spirituality as Attachment:
The Psychotherapy Treatment of Lesbian Woman Suffering from Schizophrenia
Introduction
I met Marie while training at a state psychiatric hospital in New York City during the last year of my doctorate in clinical psychology. Marie was transferred to Ward 12, the training ward of the hospital during the second month in a new position. Although I had the opportunity to see her in the therapeutic community meetings for several weeks before she transitioned to my direct care, I felt I was in no way prepared for the person I would soon get to know so intimately.
During those first couple of days on the ward, Marie looked disorganized, anxious, suspicious, and highly agitated. I learned from her medical chart that she was a 58-year-old, legally blind, obese, African-American lesbian female who had been hospitalized intermittently since 1976 for disorganized thinking, paranoid ideation, delusional beliefs, and auditory hallucinations in which she received messages from “Jehovah through telepathy.” She had a grown son, Matthew, who was her only support outside of the hospital.
During those first days on the ward, Marie was often seen wearing her full-length suede coat and carrying what seemed to be her entire wardrobe in a brown paper bag. She was also frequently waiting near the door to exit. When a staff member would inevitably kindly request she move to the side so they could pass through this door, she would glare with mistrust, yelling in a loud voice “Matthew is downstairs waiting for me!”
As it became increasing clear to Marie that she would not be going home as she hoped, she became increasingly irritable. Her anger reached a crescendo the day I was informed I would be Marie’s primary therapist. As I attempted to introduce myself in my new role, Marie charged me with an intense shuffling gate, screaming at the top of her lungs “I want to get out of here! No one is going to keep me from my family!” Shaken and stunned, I slowly moved away, wondering what I had gotten myself–or actually, been placed–into. Thankfully, the supervising psychologist on the ward arrived to replace me as the target of Marie’s intense anger.
Testing the waters once again, I approached Marie the next day to schedule our first meeting. Although she ostensibly listened as I proposed our first session, Marie glared at me with eyes registering a hostile suspicion. Although she tentatively agreed to our scheduled meeting time, she continued to size me up with a mistrusting glances as she murmured, “You are going to get yours.” This pattern continued incessantly throughout the day.
Finally feeling provoked by the verbal bards of hostility Marie kept throwing my way, I decided to take matters into my own hands: “Listen,” I said with a level of aggression that matched her own, ” I understand you want to leave. I’m here to help try to make that happen. However, if you continue to threaten me, I’m not going to meet with you.”
Taken aback, Marie first looked stunned, but then with a hint of twinkle in her eye that suggested a qualitatively different, more present relatedness, she calmly stated, “I’m sorry, but I just feel scared here.” It was clear to me that our work had begun.
Although still angrily preoccupied with escaping the hospital to be reunited with Mathew (who she insisted owned the entire building), Marie’s whole demeanor softened, just a bit, by the time of our first session. After sitting on the treatment sofa, she quickly expressed her strong frustration for being locked up, against her will, in a place that was so far from the home she longed to return: “I want to get out; I hate it here so much.”
Aligning with her sense of powerlessness in a new unfamiliar system, I allowed myself to be in touch with similar emotions about my new working environment, a place where, as a training clinician, I felt similar frustration: “I understand you wanting to leave. To be perfectly honest, I do too. This is not the greatest place in the world. I do not really have any power here, but I promise to try to help you while you are here. Hopefully, we will be able to get you out soon.” Registering with my disclosure, Marie dramatically, yet sincerely, offered me a high-five as she exclaimed, “Power to the people, baby!”
She then detailed a long list of paranoid fears, ranging from accusations that other patients and staff were stealing her clothes and money, to acute concerns about being violated in the night: “He is touching me when I am trying sleep and trying to change my sexuality; I told them I don’t swing that way, but he keeps trying.”
Rather than challenging her experience, I attempted to sincerely join Marie in her fears, ones I felt were grounded in her past, but which were actively experienced in the present. “This is not a safe place. They do bad things to people. I have to get the babies out of here.”
“Babies?” I questioned.
“Yes, my babies and I have to get out of here.”
Marie then went on to describe how she was giving birth to children who were violently abducted from her care to be placed in “a baby selling ring that was taking place across the hall; don’t you get yourself involved with that mess because Mathew is calling an FBI sting and I don’t want you to get into trouble.”
Through Marie’s express of concern for my welfare, as well as her own, I became aware of a shift in our relationship: we were now aligned as victims persecuted by the scary institutional other. It is from this position that we would build a treatment that attempted to help heal the frightening and maddening world of a victim of immense trauma.
Working through Trauma with Attachment
In our very first session, Marie had already demonstrated the way in which her internal world had collapsed around a painful re-experiencing of the trauma, as if it was happening in the present. In the language of Melanie Klein (1975), Marie proved to be essentially stuck in the paranoid-schizoid position: a psychological process in which she defensively projected painful and unprocessed aspects of her traumatic history into the lived experience of her external world. From this position, Marie appeared to experience the difficult, unprocessed, emotions of her life as vividly concrete and extremely painful in the present. Through the course of the months of treatment, I found myself entering this projected world with Marie as she continually detailed story after story of being victimized–emotionally, physically, and sexually–at the hands of various members of the therapeutic community: “There is crack in the water fountain here; they don’t think I know this, but I it’s true, Justin, I don’t lie. That psychiatrists want to kill me, I know it.”
It is interesting to note that throughout these first months of treatment, Marie kept me safely outside of the role of persecutor. To the same degree that she had externalized persecutory elements of her life onto characters on the ward, she appeared to have internalized me in an idealized form. In fact, by the second month of our work together, it was quite clear I had become her trusted source of support: “I feel so close to you, Justin. You are just like Matthew to me”
It is from this privileged position that I turned to relational psychoanalytic understanding of trauma to help in my understanding of Marie. Integrating Boldby’s (1969) attachment theory research, Pearlman and Courtois (2005) describe a relational therapeutic approach to working with victims of complex trauma that builds on the assumption that early attachment, usually from the primary caretaker, offers protection from a threatening world while providing a secure base from which the child can explore and to which she can return.
Negative experiences and disruptions in the primary bond of security with the caretaker, generally termed insecure attachment, results in severe emotional and relational difficulties. This is especially the case in situations of severe and ongoing abuse and neglect, where the caregiver is both the source of the threat and the primary attachment. It is these situations that can typically produce the insecure/disorganized attachment that characterize the psychotic symptoms of a schizophrenic diagnosis. In fact, evidence from both the posttraumatic-dissociative and attachment-development fields strongly suggests that the majority of chronically abused individuals develop an insecure disorganized attachment pattern in their interpersonal relationships (Pearlman & Courtois, 2005). Built upon the fundamental principle of the power of a meaningful connection, the relational model for the treatment of trauma fundamentally assumes that the therapeutic relationship provides an opportunity to revise the patient’s internalized attachment model; therefore, allowing the patient to begin to do the difficult work of processing the initial trauma in a safe, reparative, therapeutic environment.
As I progressed with treatment with this theoretical understanding, Marie’s behavioral symptoms slowly began to improve. Rather than menacingly threatening to harm patients and staff on a daily basis, for example, she slowly began to acclimate to the Ward 12 culture. Using my transferential place as her son, I actively intervened, suggesting she needed to make an attempt to be kind and courteous to staff; I linked this to her desire to move forward in treatment. Furthermore, I began to introduce the concept of psychotherapy as a place where she could discuss her traumatic history with the specific intention of trying to understand how her past experiences were affecting her present life.
Marie agreed to this arrangement. Although she continued to present psychotically delusional material pertaining to sexual abuse, abductions of children, and material possessions being taken away from her in the present, she also began to detail stories of history as a child who was abandoned by her mother to be left in the care of an extremely abusive man. When discussing this history, Marie would become tearful as she detailed the full extent of her of the abuse.
It was during this time that Marie first identified herself as a lesbian. She stated, from her earliest feelings of attraction, she had always known this to be the case. Although she felt comfortable with her sexual identity, Marie believed her sexuality to be the factor motivating her stepfather’s physical and sexual abuse from puberty until she left his house at seventeen: “he wanted to try to change me.” Explaining further, Marie noted the way in which her life was altered dramatically after she revealed, for the first time, that she had a crush on a girl: “I told him I had strong feelings for this girl at school and he just beat me. From then on he beat and raped me every day.” She sobbed as she started to process emotions that had been tucked away for years.
Hoping to escape to a life “where I would not be harmed,” she noted how she moved out of her stepfather’s home in order to live with “ a nice enough man” with whom she had her son, Matthew. Although she was not harmed in this relationship, “I was not in love with him at all.” She then detailed how she entered a relationship with “the love of my life,” a woman who later died of a drug overdose. She wept as she described how intensely she felt for this woman.
However difficult, by the end each session, Marie and I were able to move out of this intense place of sadness back into the present. At the end of one of these particularly emotional sessions, Marie began to note how the process of working through these memories was changing her psychic interior: “You are the first person I have ever talked about what he did to me; it’s hard, but I feel relieved.”
It is important to note, however, that Marie’s sessions were in no way free of psychotic material. Invariably, she would discuss various traumatic events as if they were happening in the present moment. After actively listening to her present delusional material, I would then question if she remembered having some similar event happen to her in the past. In one such session, Marie fervently and angrily detailed the way which Mr. Brown, one of the therapeutic aides on the ward, was “out to get me and has never liked my me and the person I loved the most in the world.” “I knew him years ago, but he thinks I don’t remember.”
“You knew him years ago?” I inquired without judgment.
“Yes, he was the one who killed the love of my life. It was his fault.”
“What happened, exactly?”
“I found her dead in the living room. It was that man’s fault. He didn’t like how much we loved each other.”
“That sounds terrible, Marie, how did your lover die?
“Of an overdose—heroine.”
“Did you feel like he contributed to her death?”
“Yes, he was always attacking her for loving me. He kept saying it was wrong and immoral, but we just loved each other. We loved each other so much.” Marie began to cry.
“I imagine it’s so hard to remember such painful memories that you have not thought about for such a long time.”
“It’s really hard; I have never loved anyone like I loved her.”
“What a tremendous loss, Marie. I’m so sorry.” Marie continued to cry, more intensely.
“Do you think it is possible that Mr. Brown reminds you of this envious man from past and the painful memory of your lover’s death, but that Mr. Brown is not actually the man who harmed you years ago?” I asked hesitantly and gently as I attempted to both acknowledge the emotions she was experiencing in the present, while also introducing the possibility it could be a traumatic memory.
“Yes, you could be right. I just miss her so much, Justin.”
“I know you do—it sounds like you were in love. I know it is hard to think about such difficult memories, but this is exactly the work I think we are here to do. I think this will ultimately help to keep you out of the hospital.”
“Maybe I imagined Mr. Brown killed her; I just miss her so much.”
The above detailed interchange captures the essential nature of our work: a movement from traumatic sensory impressions to symbolic thought and understanding that can be processed and, ultimately, worked through. In his third theory of schizophrenia, Freud (1911) conceptualized the illness as one in which an individual, due to frustrating and traumatic interpersonal relationships, is stuck in an early, traumatic, stage of development. According to this understanding, therefore, the individual withdraws from both conscious and unconscious representations of people, instead turning to a dissociated state of fantasy. Because the external world fails to provide the necessary base of security for development, the individual shifts her energy to a safer, more fantastical, internal world. In doing so, the schizophrenic individual not only inwardly retreats, but also abandons the ability for psychological representation, and psychological meaning making, as a whole. Elaborating on this point, Grotstin (1977), suggested that in those suffering from schizophrenia there is a hypertrophy of the mechanisms of splitting, projective identification, and denial to such a degree that the individual is limited in her ability to both perceive stimuli “in the real world,” and transform this perception into a manageable experience that can be available for metallization, reflection, and understanding.
Therefore, it is this process of transforming the unformulated traumatic history of the past, according to Ogden (1980), which is exactly the point of psychotherapy treatment. After the development of a new, safer, and more secure attachment is established in psychotherapy, the individual can process the undigested traumatic history in the treatment setting. Through this process, undifferentiated, chaotic, and painful traumatic material, which manifests behaviorally in the psychotic symptoms of schizophrenia, holds the potential to be transformed into symbolic thought that can be processed, mourned, and ultimately integrated into a changed psychic structure.
A brief theoretical explanation of this process, however, in no way explains the complexity of the symptoms and enormous difficulty involved in allowing this process to actually unfold. Because Marie stated she has never actually been in psychotherapy and, therefore, never attempted to move her traumatic experiences into digestible symbolic meaning, it is easy to imagine just how entrenched her psychosis remained. After processing difficult memories of her past, for instance, Marie would often request we “focus on the present and future; I just want to work on getting out of here.”
Honoring her need to regulate the intensity of her emotions, we often spent sessions discussing the concrete steps of moving forward in treatment: remaining in good behavioral control; going on van trips; attending group; and reaching out for support from others in the milieu. Furthermore, and no doubt reflecting of my deep countertransferential guilt about the enormity of Marie’s struggle in life, I found myself indulging her with trips to the canteen on these days of focusing on the present. Even in these moments when we are not doing the hard work of actively processing her traumatic past, however I believed we are continuing to strengthen a the secure attachment that allowed the more difficult work to continue in subsequent sessions.
Spirituality as Attachment
Despite the strong connection, however, this developing attachment proved to be easily upended. This fragility was dramatically demonstrated six months into our work when Marie went through a severe decomposition that resulted in chronic incontinence, increased irritability, and a level of psychosis not seen since her first arrival to Ward 12. Fundamentally precipitating this decrease in functioning was, no doubt, a reduction in her medication; however, my being called away for a training seminar, during our normally scheduled session, also appeared to trigger her symptoms.
As Marie entered the treatment room during our regularly scheduled session, she appeared angry, distant, and internally preoccupied. Immediately noticing the shift presentation, I gingerly inquired into her mental state. She responded with intense rage, “You left me!”
“I’m sorry, Marie, but I was called away to a meeting at another hospital. I should have made it clear to you that I would not be here.”
“This place is not safe; they are poisoning my food and raping me in the night. Mathew is coming to get me out of here right now.”
“I know you are disappointed and upset with me, but I do think this is a safe place for you. I really hope you can feel some measure of security while you are here.”
“I can’t trust anyone here. Jehovah says I can’t trust you either. You are just like every other doctor here, trying to feed me crack and take my money.”
“I’m so sorry Marie. I was not here for you and you needed me. I think this is a very scary place for you and I was not here to protect you. I’m so sorry.”
“I’m not scared,” she said defiantly, “I’m just going to get even!”
“Again, Marie, I’m so sorry I was not here.” Then, thinking of her resilience, I asked, “I’m wondering, what did you do to comfort yourself in my absence?”
“I prayed to Jehovah; he is always here for me.”
“I think this is a great idea, Marie. I think we should pray to Jehovah right now, in fact. I think we should say a prayer to keep you safe and secure.”
After looking at me of bewilderment and deep suspicion, Marie agreed to say a prayer. She first prayed for her safety alone, but allowed me to join in at the end with a quiet “Amen.” She then went on to say another prayer that included a supplication for both of our safety and concern. After this second prayer, Marie’s entire demeanor softened and she began to cry: “You know, I just missed you so much. It’s so hard here.” Relieved at the change in her demeanor, I empathized with her sadness.
I take the time to detail this story both to emphasize the fragility of Marie’s attachment, but also to introduce her spirituality as a central, sustaining, and essential aspect of this bond. In fact, it is my contention that it is her enduring belief in the transcendent “power of Jehovah” that has served as Marie’s primary attachment, one which has both sustained her through years of chronic, severe abuse, and allowed her to have the courage to extend herself, beyond her inner world, to me in our work together.
Whenever I have inquired about the factors which helped Marie to survive her extensive history of abuse and neglect, for example, Marie repeatedly referred to her continual surrender to her belief in a transcendent source: “Jehovah will provide.” Although this religious language has historically been viewed as a kind of dissociative defense in the field, I see it as a central element of her resilience. It is Marie’s strong spiritual beliefs, therefore, that have provided a context in which we were able to do the difficult trauma work previously described. In short, it was this primary relationship with Jehovah that served as a relational bridge to our therapeutic relationship.
Building on this notion, Cynthia Stone (2005) describes an integration of a patient’s spiritual beliefs into the treatment as a kind of dance or opening of the “analytic third” (Ogden, 1994) in which both the clinician and the patient “engage with spontaneity and openness to the unconscious with the ultimate hope that such interplay will lead to the transformation of the patient in the direction of greater self-transcendence.” By respecting and working with this transcendence source of meaning, both the patient and therapist have the opportunity to surrender more deeply and powerfully into the possibility of finding a new self-organization. By opening ourselves to transcendent third, therefore, we allowed for an exponentially greater potential for healing.
Our Ending, for Now
This opening continued until my last days of the training year at the hospital. As my appointment came to a close, I slowly began to discuss my departure from the hospital. Introducing the topic of ending our work together, Marie responded with a loud streak of concern crying, “You are leaving me?”
“Yes, I’m sorry, but I will be ending my training in the hospital in a couple of months.”
“Can you visit me in the nursing home?” Referring to her placement after her stay on the ward, she asked this question as she shook uncontrollably and audibly passed gas.
“No, Marie, I’m sorry, but I can’t. I’m your therapist and our work is here, in the hospital.” I was feeling horribly guilty, as though I was abandoning someone who had so graciously taken me into her life. I continued, “But, that does not mean we cannot hold in our hearts the great work we have done this year; I truly believe you have allowed me to connect with you on a level that that transcends our connection here on Earth.”
“Jehovah says you are right. I will see you again on the other side.” She stated as she started to cry.
“I love you, Justin.”
Unable to back my own tears as I thought about how her connection to the Divine was such an integral aspect to her ability for such a sincere emotional connection in that moment, I said, “I love you too, Marie.”
REFERENCES
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Freud, S. (1911). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides).
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Klein, M. (1975). Love, Guilt, Reparation and Other Works 1921-945. New York: Delacourte Press.
Ogden, T.H. (1980). On the nature of schizophrenic conflict. International Journal of Psychoanalysis, 61, 513-533.
Ogden, T.H. (1994). The analytic third: Working with intersubjective clinical facts. In S.A. Mitchell & L. Aron, eds., Relational psychoanalysis: The emergence of a tradition. Hillsdale, NJ: Analytic Press, 1999.
Pearlman, A.P & Courtois, C. (2005). Clinical Applications of the Attachment Framework: Relational Treatment of Complex Trauma. Journal of Traumatic Stress, Vol. 18, No. 5, 449-460.
Stone, C. (2005). Opening psychoanalytic space to the spiritual. Psychoanalytic Review, 92, 417-430.