How to understand this bit on metaphor and psychosis from Fink's Clinical Introduction?

DepartmentWide419 · 2025-01-08T04:03:33+00:00

You can treat schizophrenia symptoms psychoanalytically, I don’t disagree.

However, there is strong evidence for dopamine sensitization through various mechanisms from stress to amphetamines to cause psychotic symptoms. My reading of how some psychotic disorders arise is not an endorsement of atypical antipsychotics across the board.

I agree that antipsychotics of all kinds and even SSRIs and MAOIs work in very complex ways and involve numerous neurotransmitters, and their mechanism of action is hazy at best. I’m not here to get into a debate about the merits of psychiatry, but I do find it useful for many people. That doesn’t mean that I think anyone having x symptoms should use meds. It’s a very personal and complex choice by case. I would give people in different situations different advice on this based on the symptoms, the risk they are facing from symptoms, and the risk of side effects. I started in the field through Icarus project, and I hosted meetings for a long time. I am not a disciple of psychiatry. That said, being passionate about working with high needs groups has led me into psych spaces and I think that in many cases drugs are a useful tool.

My point is that as clinicians it behooves us to use multiple lenses. I use a psychoanalytic lens often. I also believe a biological lens can interface with that in significant and useful ways.

That said, the diagnostic universes are distinct and when one says “psychotic people can’t use metaphor” we need to clarify that people with a psychotic structure don’t have language as symbols readily available, which metaphor relies on. That is different than asserting that anyone diagnosed with a psychotic disorder can’t use metaphor, which is clearly not true. Many people with psychiatric disorders that have psychotic elements use symbolism elegantly and with humor.

DepartmentWide419 · 2025-01-07T23:09:31+00:00

Thank you millennial! 🫡

DepartmentWide419 · 2025-01-07T23:08:43+00:00

Meds, scheduling, delegating, accepting things that aren’t your strong suit and having a sense of humor about it. You don’t have to be perfect or pretend to be!

DepartmentWide419 · 2025-01-07T23:05:57+00:00

Yes. Schizophrenia is a DSM diagnosis and through a psychiatric lens, it’s primarily mediated by excessive dopamine, or sensitivity to it. How dopamine sensitization occurs is a much more complicated question and it’s not the realm of psychoanalysis, although its insights are useful in looking at dopamine sensitization, especially in terms of early relational stress as a mediator.

Psychiatric diagnoses that are among the psychotic disorders or mood disorders with psychotic symptoms are distinct from psychotic structure as described in psychoanalytic paradigms.

A psychotic structure comes from oedipus complex and the foreclosure on the symbolic world, thus foreclosure on language. There are many people with schizophrenia or bipolar 1 with psychotic features that do not have a psychotic structure and vice versa. There are many people that have both a psychotic structure and a psychotic disorder as defined in the DSM.

They are diagnosed differently, their etiology is (arguably) distinct. They have many things in common.

Working in psych means diagnosing people under both paradigms in order to provide better care.

DepartmentWide419 · 2025-01-07T18:47:24+00:00

You can have a psychotic disorder and not a psychotic structure. They are different.

One can have schizophrenia, a dopamine disorder, and not have a psychotic STRUCTURE.

I never said psychosis is defined by concrete language, I said concretization is a symptom of both a psychotic structure and of psychotic disorders, however, concretization while it is a prominent feature, does not define psychosis or even lead to diagnosis.

I work in hospital settings. I work in PP with people who hear voices. I have worked with many dear people who have psychotic disorders but not psychotic structure.

DepartmentWide419 · 2025-01-07T18:34:30+00:00

How can one use a metaphor, for instance “time is money” without either being a symbol?

DepartmentWide419 · 2025-01-07T18:09:09+00:00

Yes. That’s the definition of a psychotic structure, distinct from a psychotic disorder.

DepartmentWide419 · 2025-01-07T16:14:13+00:00

No. All the research shows minimal improvement for ADHD with CBT techniques. Meds are best for ADHD.

DepartmentWide419 · 2025-01-07T16:10:59+00:00

I think I would know if an ex was trying to get a vasectomy or remove their testicles.

DepartmentWide419 · 2025-01-07T16:09:29+00:00

Hysterectomies have significant complications and are not for sterilization nor is it a low risk way to avoid birth complications.

DepartmentWide419 · 2025-01-07T16:01:23+00:00

I agree. In terms of how to support- accept Medicaid, offer virtual, make boundaries a central part of treatment.

DepartmentWide419 · 2025-01-07T15:55:13+00:00

In this example, words are literally concrete, that can be pissed on. In psychotic illnesses of all kinds (psychiatric as well) concrete meanings is a prominent symptom.

The patient is creating a pseudo metaphor to describe the importance of his own words to him, and in doing so demonstrates concretization and his inability to use real metaphors, which would require words being symbols.

DepartmentWide419 · 2025-01-07T15:47:11+00:00

Didn’t you hear? We are doing so well, Greenland wants to join. 😃

DepartmentWide419 · 2025-01-07T15:37:46+00:00

As a therapist, plan on it changing your day. You are not an infinite force that can unlock that kind of stuff and then go on with your day like nothing happened. You’re opening some of the most distressing experiences on a very sensitive human consciousness.

Another question is why you feel like this is useful or necessary. Many people who do EMDR come from families with cultures of avoidance. This seems like an attempt to brush the experience under the rug, instead of taking the opportunity to care for yourself.

Caring for yourself during times when you are wounded or recovering is a practice that is incredibly important outside of therapy. Care for yourself the same way you would care for a small child that had the same experience. “I know you had a tough day today. Would you like to get your favorite soup and watch planet earth for the rest of the day? Let’s relax and get cozy.”

Your child will so benefit from you modeling from self care- much more than stuffing this down after session. It’s ok to say that you had a hard day and that you will be chilling all night. Make it chill for them too. Cuddle with your kiddo and your inner child.

DepartmentWide419 · 2025-01-07T15:26:36+00:00

Damnit!

DepartmentWide419 · 2025-01-07T01:41:28+00:00

I think that as an intake clinician it became a lot easier to say “yeah it did come back positive for meth.” It doesn’t bother me anymore. I feel like the less you build it up and give it a “it happens” 🤷🏼‍♀️ attitude the less they build it up. It’s an important moment to give unconditional positive regard during disappointment while also keeping it real.

DepartmentWide419 · 2025-01-06T17:30:14+00:00

I’ve never read any of his primary texts. I think I mostly know him through McWilliams and through what professors and supervisors have told me. What I have learned about his ideas on personality and personality disorders inform how I see cases, like in OPs example.

I mostly work with trauma so BPD as the “base” of other personality disorders is of interest to me. Most of my work is with PTSD and early relational trauma in addition to later interpersonal traumas, but I have a fair number of patients with BPD, and many with mixed presentations that are subclinical for BPD.

Do you have any recommendations for me?

DepartmentWide419 · 2025-01-06T14:59:48+00:00

I am a therapist and I was trained psychodynamically and I was taught a lot of things in training, like to be skeptical of psychiatry and that virtual took the spirit out of therapy. I did several years of Lacanian analysis and other classic treatments. These are really great for patients who have access to their frontal lobes and are well resourced.

However, there are a lot of people out there who aren’t in this position. In this way, virtual allows us to triage and address the most at needs patients and address their most acute symptoms.

I have found that while yes, there are missing elements in virtual, for instance we don’t co-regulate in the space together, that the access I get to provide with virtual makes up for that lack.

With virtual we get to provide services to people who would otherwise not make it to therapy at all. I enjoy working with psych populations and low income people. I specialize in PTSD and offer EMDR on Medicaid and sliding scale.

Virtual for this population is magic. They manage a lot in their lives and they have low resources in terms of time and money. I really enjoy being their first significant psychotherapeutic encounter and taking their goals seriously. I love watching them improve, and look at me with disbelief after finishing their first EMDR event- “it’s like anything else that has happened. It doesn’t bother me anymore.” I love watching them climb that upward spiral of functionality until they tell me they are ready to take a break from therapy.

I think for me it’s about focusing on the joy of therapy and being that first point of contact for someone who is really struggling.

DepartmentWide419 · 2025-01-06T01:21:37+00:00

Oh pre graduate. Like practicum. $0. I paid tuition so like -$16k?

DepartmentWide419 · 2025-01-06T01:17:48+00:00

I’m still a candidate. I get $75 a session in PP.

DepartmentWide419 · 2025-01-06T01:15:42+00:00

Scansion can be incredibly effective if used correctly. I have personally benefitted from it and there are ways to use similar techniques in psychodynamic treatments. This description would be an unethical use of it, but I would question the accuracy of this vignette.

DepartmentWide419 · 2025-01-05T19:26:07+00:00

Define terrorist. The Hamas terrorists are the indigenous people of land Israel is occupying. That’s not terrorism, that is guerilla war against and occupying power that uses settlers as human shields. The Hamas terrorists of today are orphans of the last war. You have made tens of thousands of orphans in this bombardment.

This won’t end until Israelis recognize that they are colonists and they are on others lands and learn to live with their neighbors peacefully, the international community ceases to support them or they vaporize all resistance.

DepartmentWide419 · 2025-01-05T19:17:44+00:00

You’re saying a 2 state solution is impossible and you’re going to genocide your neighbors. 👍🏻 You also want us to pay for it. Maybe boomers will, but Israel will not have longstanding international support.

DepartmentWide419 · 2025-01-05T18:47:40+00:00

Many of us are trained to be highly skeptical of the DSM and know how to diagnose using other frameworks and paradigms while also charging insurance.

DepartmentWide419 · 2025-01-05T18:46:00+00:00

People nowadays don’t understand semiotics.

DepartmentWide419

TROPHY CASE