The Use of Hallucinations in the Treatment of Psychotic Patients

Abstract

"No one understands hallucinations." The speaker might have been a psychiatrist or psychologist, but, in fact, he was a patient. Patients like to say that. But hallucinations are simply wide-awake dreams, readily understandable by Freud's psychology of dreams, with minor modifications. Hallucinations are at least as useful in the treatment of psychotics as dreams are in the treatment of neurotics. After all, psychotics are more puzzling and are less likely to communicate clearly. They are also less likely to report dreams until they stop hallucinating. The capacity to hallucinate while wide awake, however, is not restricted to psychotics. All of us knew, long before we were therapists, that starving people hallucinate food, and people dying of thirst hallucinate water. These are obvious wish-fulfillments; the need simply has to be stronger to dream while you are wide awake. A British study (Breheny, 1990) found that of the many people who hear voices, only 40% had ever been treated by a mental health specialist. Those whose voices were particularly terrifying, destructive, and overpowering found this helpful; those whose voices were comforting resented the interventions of the professional. Those who had talked to a clergyman or friend reported it as more consistently helpful. Twenty-four percent did not talk about it to anyone. This was because they did not want the voice to go away. The voice started when they were under stress, for example, after a parent or spouse died: the voice says, "You're doing fine," "It's okay," or some other comforting words from someone they wish were still around. They did not need Freud to tell them this was a wish fulfillment. Psychotic hallucinations also may mean that the patient is lonely; the voices represent somebody who cares about them. But even malevolent voices are better than being alone. Any child would rather be punished than ignored; and all adults, sick or well, still carry the seeds of their childhood within them. In primitive cultures, hallucinations are not uncommon but the well adjusted hear and see them only under culturally appropriate circumstances, while the emotionally disturbed hear and see them under culturally inappropriate circumstances. Schizophrenics may hallucinate in any sensory modality but, as Eugen Bleuler (1950) pointed out, almost all schizophrenics hear voices. Predominantly visual hallucinations, particularly moving animals in color, suggest a toxic psychosis. These patients should be asked about their use of alcohol and other drugs. This relationship between visual hallucinations and toxic psychosis was ignored by researchers who tried to tie schizophrenia to LSD and other chemical substances (Karon & Vandenbos , 1981). But these chemically induced psychoses had all the characteristics of toxic psychoses, that is, a predominance of visual phenomena. The predominance of auditory hallucinations, on the other hand, means that schizophrenia is basically an interpersonal disorder. People who are deaf tend to have more psychological problems than people who are blind. Blind people are more physically incapacitated, but deaf people are more cut off from other human beings. The voice is the most general connection to other people. The problems that lead to schizophrenia are the result of disturbed relations with other people, and it is these disturbed relations that the patient is trying to resolve. Hallucinatory material-whether auditory, visual, odoriferous, or any other-should be treated like a dream; that is, it should be described, associated to, made sense of, and brought meaningfully into the context of the patient's problem. Nearly as common as the myth that no one knows what hallucinations mean is the secondary myth, that whatever they mean ought not to be disclosed to the patient, and that the very search for meaning is destructive. Many mental health professionals, including some psychoanalysts, believe that the patient should be directed toward reality and not encouraged to explore their hallucinations. …