Illness identity: Therapy as a path to wholeness and integration

I have noticed in recent years a greater prevalence in how people talk and think about their experience of psychologically dysphoric states. States such as anxiety, low mood, compulsivity, and distraction are not just described as subjective experiences, but also as concrete pathologies owned by those who experience them (Karnilowicz, 2010). These expressions of ownership are associated with the proliferation of individuals referring to pathologies as theirs: “my trauma”; “my anxiety”; “my ADHD.”

Implied in these proclamations is the notion that such pathologies have lodged themselves inside the individual like a virus. The individual sees themselves as if they have been invaded by a foreign pathological body that is held within them. Furthermore, no degree of agency or a role in such ownership is reflected in the description of such dysphoric states. These states might be conceptualised as genetically inherited or wired into them. These deterministically acquired afflictions lead to othering, stigmatisation, and shame. Questioning the individual's way of conceptualising their suffering risks being interpreted as invalidating or traumatising (Pierce, Kostova, & Dirks, 2003).

Psychoanalysis and illness identity 

Practitioners aligned with psychoanalytic or psychodynamic thinking around illness identity may be more likely to simultaneously recognise the etiological and psychosocial factors that sustain illness and also remain open and curious about the unconscious function that identification with illness and diagnostic labels serves.

What psychodynamic or psychoanalytic theoretical models generally share is the premise that external circumstances (e.g., events considered traumatising or characteristic of societal oppression) are perhaps a necessary but insufficient condition for the development of psychopathology. External circumstances interact with and hook onto elements inside the mind that existed before the external event occurred. A common factor of these elements within the mind is that they can belong to one of two psychological processes

One of these processes is characterised as being driven toward interpersonal connection, drawn to life-affirming pursuits, engaging in reciprocal relationships, and capable of feeling compassion and appropriate guilt. I’ll call this the “relational” process. Conversely, the “anti-relational” process is driven towards destructive acts, transactional relationships, envious comparison with others, and, by its nature, sees the world and others as a threat (Hillenbrand & Money, 2015).

Various psychoanalytic theories and models of the mind propose the idea of two opposing processes within an individual. These processes can help us understand the unconscious mechanisms that drive an individual to identify with. Furthermore, they aid in understanding the individual's struggle to relinquish the notion of a pathology they have ownership of.

Paranoid-schizoid and depressive states

Melanie Klein's (1946) concepts of the 'paranoid-schizoid' and 'depressive' states offer a means to understand an individual’s wish to have or claim ownership of a pathology. It's important to note Klein did not mean “depressive” in the sense of low mood or depression as we normally understand it. I will explain Klein's meaning of depressive states later on.

The paranoid-schizoid state is marked by a fragmented perception of self and others. Individuals in this state may engage in transactional relationships, where interactions are based on what others can do for them, rather than seeing others as whole beings who are more than the function they serve for the paranoid-schizoid individual (Klein, 1946). For example, an individual operating in a paranoid-schizoid state hiring a sex worker will not see them as a whole person but rather as a means of gratifying their sexual urge.

This state is also associated with viewing the world and others as threats, reflecting a defensive, self-protective stance. This mirrors the characteristics of the anti-relational process I described earlier, which is driven towards destructive acts, secrecy, and comparison with others (Bermúdez, 2018).

Central to paranoid-schizoid states is the process of projection, where unwanted or destructive aspects of oneself are attributed to factors external to the self. In the context of an individual’s tendency to identify with or claim ownership of a mental illness, destructive impulses or parts of them that threaten their self-concept are attributed to diagnostic labels or the illness they believe afflicts them.

Conversely, in depressive state functioning, individuals transition towards seeing others as a whole and are comprised of both good and bad parts. This relational process is characterised by the ability for interpersonal connection, life-affirming pursuits, and reciprocal relationships. Individuals occupying a state of depressive functioning are inclined to feel compassion and appropriate guilt.

The transition from paranoid-schizoid to depressive states involves confronting and integrating self-defeating and destructive aspects of the self. It requires acknowledging that the destructive parts, previously projected onto diagnostic or psychopathological labels, are a part of oneself. This process involves experiencing difficult emotions associated with this reclamation, such as guilt, and the pain of recognizing one's capacity for destructiveness. Ultimately, it is also self-compassionate, as within this is the recognition that the capacity for destructiveness is woven into the universal fabric of the self.

The purpose of thinking about dual states in therapy

Part of psychodynamic or analytic therapy requires the practitioner to be attuned to which state the patient occupies with them at a given time. This can fluctuate in the course of a session. Paranoid-schizoid states and anti-relational processes are inclined to become activated in times of stress and heightened anxiety.

The clinician who understands such states and is aware of their fluctuations can help the individual, over time, to first recognize the ways they adopt and mobilise paranoid-schizoid, anti-relational processes. This is a first step towards insight and can assist the individual in gradually reclaiming self-defeating and destructive impulses that were hitherto attributed to pathologies experienced as foreign to the self.

Perhaps a paradoxical benefit of this transition from paranoid-schizoid, anti-relational to depressive, relational functioning is that the individual can begin to reclaim, accept and develop ways of mitigating destructive parts of themselves. Ultimately, this reclamation can facilitate the development of an understanding of the context in which such destructive parts developed, which often have their genesis in early traumatic experiences. Such an understanding can be vital for moving from the anti-relational, paranoid-schizoid process of blaming others for past betrayals or traumas to a depressive stance of self-compassion.

Depressive self-compassion is not inherently an abdication of responsibility but is an acknowledgement of suffering and can involve a process of grieving lost or hitherto undeveloped parts of the self. This can be profoundly self-empowering. Thus, the reclamation of destructive and other disowned parts is in itself an act of depressive and relational functioning, which facilitates the self-experience of wholeness, and, ultimately, integration. As Carl Jung (1958) said, “wholeness is not achieved by cutting off a portion of one’s being but by integration of the contraries.”

Sources

-Bermúdez, J. (2018) ‘Bodily ownership, psychological ownership, and psychopathology’, Review of Philosophy and Psychology, 10, pp. 263-280.

- Hillenbrand, C. and Money, K. (2015) ‘Unpacking the mechanism by which psychological ownership manifests at the level of the individual: A dynamic model of identity and self’, Journal of Marketing Theory and Practice, 23, pp. 148-165.

- Jung, C.G. (1958) The Collected Works of C.G. Jung: The Structure and Dynamics of the Psyche, 2nd ed. Princeton, NJ: Princeton University Press.

-Klein, M. (1946) ‘Notes on some schizoid mechanisms’, in Envy and Gratitude and Other Works 1946-1963. London: Hogarth Press, pp. 1-24.

-Karnilowicz, W. (2010) ‘Identity and psychological ownership in chronic illness and disease state’, European Journal of Cancer Care, 20, pp. 276-282.

-Pierce, J. L., Kostova, T. and Dirks, K. T. (2003) ‘The state of psychological ownership: Integrating and extending a century of research’, Review of General Psychology, 7(1), pp. 84-107. doi: 10.1037/1089-2680.7.1.84.

-Steiner, J. (1979) ‘The border between the paranoid-schizoid and the depressive positions in the borderline patient’, The British Journal of Medical Psychology, 52(4), pp. 385-391.

-Steiner, J. (2014) ‘The equilibrium between the paranoid-schizoid and the depressive positions’, in Melanie Klein Today, Volume 1: Mainly Theory: Developments in Theory and Practice. London: Routledge, pp. 46-58.