Academic journal article American Journal of Psychotherapy

Imprisoned Royalty: Defensive Failure and Reconstitution

Academic journal article American Journal of Psychotherapy

Imprisoned Royalty: Defensive Failure and Reconstitution

Article excerpt

Treatment of schizophrenic patients in an inpatient setting has become evermore challenging over time. Patients move in and out of hospital systems quickly, and the severity of patients' illnesses during their hospital stay makes the experience chaotic and intense. This paper offers a model for understanding psychotic patients' experiences on an inpatient unit, and for effectively working with them in this setting. I have drawn on a parallel in film, that of "The Madness of King George," to help illustrate the concept of the hospitalized schizophrenic patient as imprisoned royalty. Through this metaphor, I explore the process of defensive breakdown and repair in psychosis, as it occurs in the hospital setting. I examine the relationships between patients, clinicians, and aspects of the hospital, and review some of the common dilemmas in this type of treatment.

Schizophrenic patients and others with acute psychoses find their way into today's inpatient wards with great regularity. Their treatment is a challenge familiar to most of those involved in this work: short inpatient stays, medication noncompliance, immutability of symptoms, and institutional systems problems are but a few of the obstacles to be overcome. The object of this paper is to highlight the experiences our patients have while they are with us, and to discuss some of the dilemmas we and they encounter in our work together.

People who have been hospitalized on an inpatient unit suffer, first and foremost, from a failure of their defenses to keep them protected enough to safely walk in the world with others. Often, these defenses are primitive to begin with, and may be just intact enough to allow their owners to live in reasonable peace, some of the time. Because of their long associations with psychosis and its vicissitudes, relationships with other people lack the luxury of safety and intimacy that many of the rest of us enjoy; their special status outside the mainstream can easily lead to their feeling different from the common man, either inferior or superior to him.1,2

A hospitalized patient with an illness in the psychotic spectrum can display a grandiosity and brittle interpersonal style that comes with a particular and unique understanding of social graces. He can, in fact, behave more like doomed, imprisoned royalty than a collaborative partner in the treatment of his mental illness. Vast misunderstandings and intense frustrations may ensue on both sides of the treatment fence when his doctors treat our man like any other; the defenses that might permit him to see himself as his treaters see him have been shattered, and he is desperately trying to repair them.

This concept of imprisoned royalty calls for illustration and exploration, as it might apply to our hospitalized patient. There are many examples of weakened, vulnerable monarchs in literature and film that represent this dynamic situation. What stands out in a review of the attitudes of kings is the sense of loneliness, the need to suspect even one's closest kin of murderous intent, the absence of sources of reliable comfort, especially when everything that had been trusted is suddenly, violently changed. I think of the rulers in Greek mythology, and of Elizabeth and Mary, of multitudes of monarchs who, even in the absence of madness, found themselves desperately protecting their crown and their lives with aggression, paranoia, and in many cases, desperate acts to preserve their power and avoid destruction at the hands of those they rule.

In this paper, I have used excerpts (some paraphrased) from the film "The Madness of King George"(1). Here we find a king who has gone mad, his experiences with people caring for him, his suspicions, and his desperate and conflicting needs. In a combination of examples from this work of fiction and from clinical life in the psychiatric ward, I will attempt to clarify parallels and offer suggestions for treatment approaches to these patients in their hours of need. …

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