The Volkans on Schizophrenia

Nearly a decade ago, I began exploring the underlying psychodynamics of ISIS propaganda, and the wider historiography of the Crusades. In the course of that research, I think it was the historian and psychoanalyst Charles Strozier (in his book  The Fundamentalist Mindset: Psychological Perspectives on Religion, Violence, and History) who first introduced me to the works of Vamik Volkan and his pioneering and pivotal concepts of "chosen trauma" and "chosen glory." 

I went on to read several of Dr Volkan's books, including Bloodlines: From Ethnic Pride To Ethnic Terrorism. These and others of his corpus have been very helpful to me in several articles and lectures, and now in a book I have coming out later this year on the dynamics of Russian-Ukrainian historical and religious conflicts. 

More recently, as readers may recall, I interviewed him about his Large Group Psychology which was published by Phoenix in 2020. (By all means order the books through Phoenix directly where you will often get a discount.)

All this is to say that when I learned last year that Phoenix was publishing a new book he co-wrote with his son Dr Kevin Volkan, and that the book was on schizophrenia, about which I have been reading extensively since last fall, I was very excited and determined that I must read it, as I have now done, and also determined to interview the authors, as they have also now graciously consented to doing. 

Before turning to their thoughts, let me further entice you to order their new book Schizophrenia: Science, Psychoanalysis, and Culture by pointing out just two of its paramount virtues (and leaving you to discover the rest for yourselves): first, there is a consistent and wholly welcome modesty throughout the book. It is sometimes put about by lazy and uninteresting people (who are usually engaged in projective identification) that those of us who operate psychodynamically are hide-bound rigid ideologues rejecting all other forms of psychotherapy, from drugs to CBT to whatever this week's acronym du jour is. But, as you will presently read, while both Volkans (père et fils) are clearly steeped in psychoanalytic thought and approaches, they do not brandish any of that as a means of denigrating or dismissing pharmacotherapies and CBT. Time and again throughout the book one encounters--if you will--the "subjunctive mood" on many occasions. Their language is modest and quite sincerely so: regularly one reads that some people may be helped by some of the treatments examined here, but that no treatment is appropriate for everyone. There is no totalizing language here buttressing sweeping claims!

This is all embedded in a book whose first half looks at contemporary neurological and aetiological research into schizophrenia and acknowledges the use of psychotropics as being helpful, whether as stand-alones or as adjuncts to other therapies. It also examines CBT approaches and recommends some of those where appropriately indicated.

Second, and related to this first virtue, is the extensive attention paid--in the final quarter of the book--to cultural questions about the history, diagnosis, manifestation, and treatment of schizophrenia outside a middle-class American context in the early 21st-century. This too marks the book out as distinct in my (so far limited) experience in the field. 

With that in mind, let us turn to our two very distinguished authors and hear from them. 

AD: Tell us about your backgrounds

Kevin Volkan, EdD, PhD, MPH (KV) is a founding faculty member and Professor of Psychology at California State University Channel Islands. He also currently serves on the Graduate Medical Education faculty for the Community Memorial Hospital System in Ventura, CA, and as an adjunct faculty member for California Lutheran University’s clinical psychology doctorate program. 

Vamık D. Volkan, MD (VDV) is the author, co-author, editor, or co-editor of over fifty psychoanalytic and psychopolitical books. He is an Emeritus Professor of Psychiatry at the University of Virginia, Charlottesville and an Emeritus Training and Supervising Analyst at the Washington Psychoanalytic Institute, Washington, DC. In 1987, Dr Volkan established the Center for the Study of Mind and Human Interaction (CSMHI) at the School of Medicine, University of Virginia. He is the President Emeritus of the International Dialogue Initiative (IDI), which he established in 2007. 

As we say in the foreword of the book, we come from different but overlapping backgrounds. We give a more comprehensive overview of our backgrounds there.

AD: What led you to write this book on schizophrenia now?

VDV: Many individuals with this condition do not get enough or necessary treatment. Many are out there wandering around. It is important to bring attention to this mental/societal condition.

KV: Where I live in Southern California, we have an enormous homelessness problem. This is also true in many other parts of the country. Driving through downtown Los Angeles, it’s hard to believe that this is America. Conservative estimates are that around a third of the homeless population have severe mental illnesses – usually schizophrenia. 

So, although this disorder is a big problem, there has been little progress on how it is understood and treated over the last 50-100 years. The scientific understanding of the biological roots of schizophrenia has made great strides, but this has not yet translated into better treatment and care for people suffering from schizophrenia. 

But there are several new treatment possibilities on the horizon. Some of these new treatment methods include various types of psychotherapies. While psychoanalytic-derived treatments have been around for a while, these have not often been applied to psychotic individuals, especially in the United States. People like my dad have been working with those who suffer from schizophrenia in an in-depth way. He has learned a lot about schizophrenia and has important insights into how psychotherapy can be used to treat it. Our book is an attempt to communicate this insight as well as to document the state of schizophrenia research and treatment as it stands today.

AD: What is it like co-writing a book, especially as father and son?

VDV: One of the best things that ever happened for me. I felt very proud of my son, a great academician.

KV: Working on this book with my dad has been a wonderful experience. I was a bit nervous at first since he is such a luminary in the field. But the writing process went very well and was a chance for us to get to know each other and become closer.

AD: You note (p.19ff.) that cannabis use has been linked in a number of studies going back over a decade to increased rates of and risk for schizophrenia. Tell us a bit about some of those findings and your views on them. Given the increasing popularity and legalization of cannabis in North America, do clinicians need to be extra vigilant in screening for use? Are we as a society proceeding too fast in tolerating or even encouraging recreational use of cannabis?

KV: There are many studies that link the development of schizophrenia and cannabis use. The causal direction of the relationship is not entirely clear. For instance, do people who have a predilection to developing schizophrenia self-medicate with cannabis in a prodromal phase or do they use cannabis which then triggers the onset of psychosis? The latest research suggests that the latter is more likely especially among adolescents. Early age of cannabis use, and frequency of use seem to be predictive of significant risk for developing schizophrenia among vulnerable young people. 

Cannabis has not, as far as I know, been legalized anywhere for adolescents. Will legalization cause in increase in adolescent cannabis use? Maybe, maybe not. We are in the middle of a ‘natural experiment’. Will legalization cause a spike in first episode schizophrenia? A study by Vignault et al. in 2021 in Canada found that cannabis use among adolescents did increase when cannabis was legalized but did not seem to cause an increase in diagnoses of psychotic disorders (interestingly, there was a modest increase in personality disorder diagnoses). So, I think the jury is still out about the relationship of cannabis legalization to schizophrenia.

What I advise my undergraduate students and as well what I tell my clinical psychology graduate students to tell their patients is the following:

• Early cannabis use is bad. Children and adolescents should not use cannabis period, especially given the increased strength of the drug. 

• For people in their 20s there is some risk from cannabis use, especially if they are chronic users of strong cannabis. If there is no family history of psychoses and the use is occasional, the risk of developing schizophrenia is not zero, but is low.

• For people with a first-degree relative diagnosed with schizophrenia or another psychotic-adjacent illness they should not use cannabis at all. This is especially true for kids and young adults. 

• People who are diagnosed with schizophrenia or a psychosis adjacent illness should not use cannabis.

• Adults in their 30s -50s who do not have schizophrenia or something similar and who do not have first-degree psychotic relatives are not likely develop schizophrenia because of cannabis use.

• Adults older may find some cognitive benefit from cannabis use, again provided they do not have a schizophrenia or similar diagnosis.

These recommendations are speculative and subject to change when better research becomes available. (See Vignault, C., Massé, A., Gouron, D., Quintin, J., Asli, K. D., & Semaan, W. [2021]. The potential impact of recreational cannabis legalization on the prevalence of cannabis use disorder and psychotic disorders: A retrospective observational study. The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie, 66, 1069–1076.)

AD: You mention (p.76) that Searles (whom I wrote about here) suggested clinicians treating schizophrenia need to pay attention to the counter-transference. But this theme is not much developed in the rest of the book. Would you want to elaborate some thoughts on that here?

VDV: The psychology of analysts and therapists undertaking intense work with people with schizophrenia needs consideration; for example, their ability “to regress in the service of the other” is crucial. The necessity of tolerance and therapeutic use of countertransference in treating patients with schizophrenia demands that the therapist meet the patient in his or her regressed state and, in a sense, validate it without intruding into the therapeutic space. The patient must feel that he or she is not alone in a strange place. This conduct helps change the patient’s regression from chaotic to therapeutic. Because of their own psychological make-up, certain analysts or therapists may be better equipped than others to use their personal responses to the patient’s primitive activities. Training is important, but most psychoanalytic institutes do not provide the necessary training.

AD: Your 13th chapter on object relations theory was one that I resonate deeply with. There, and in several other places in the book, you speak of schizophrenia patients as "object hungry." Would you elaborate a little bit on that concept for our readers?

VDV: The patient with schizophrenia is hungry for libidinal experiences, but this hunger is never satisfied. An attempt is made to collect "good" images in order to libidinalize the infantile and adult psychotic selves, but the patient also collects "bad" objects under the influence of repetition-compulsion, and certainly in the patients’ experience what is “eaten” as good might easily turn out to be bad.

Utilizing its available ego functions, the infantile psychotic self, like the early computer game character Packman, is doomed to “eat up” anything in front of it, without finding any food that is nourishing. The infantile psychotic self’s main ego function is internalization. 

But it also evacuates constantly what has been “eaten.” Therefore, its other main ego function is externalization. Here I am using the terms internalization and externalization to separate these functions from more sophisticated introjection and projection mechanisms in which there is some fit between what is projected and the target and between what is introjected and the reality of the object before it is taken in. Such fits do not exist in externalizations and internalizations. At times even these primitive ego mechanisms are not functional. The infantile psychotic self simply fuses with objects, only to separate from them.

AD: The number of chapters devoted to cross-cultural understandings of schizophrenia was itself hugely impressive, going far beyond what I've found in numerous other recent works. Why was it important for you to include this material?

KV: While the prevalence rates of schizophrenia are similar around the world, the ways in which it is related to specific cultures varies a lot. The relationship between schizophrenia and how specific cultures deal with the disorder can provide many insights into understanding, preventing, and possibly treating schizophrenia. 

These chapters also point out that there may be different kinds of schizophrenia with some versions having a more ‘physiological’ etiology (qi gong psychosis for example) with other versions deriving more from societal conditions (for instance Saora psychosis). The idea that people in the developing world are less likely to have subsequent psychotic breaks after their first episode has been floating around. This may be related to not being treated with antipsychotic medication on first presentation or may reflect something in the culture which provides some resilience. 

Additionally, there is a lot of research about the increased risk for schizophrenia among immigrants. Switching cultures may undermine cultural resilience in several ways. I am especially interested in cultural variation in early object relations as something that possibly can prevent schizophrenia from developing in people who have a propensity for the disorder.

AD: You note (pp.116-17) that it may be important for psychotherapists treating schizophrenia to have a more fully developed "potential for regression in the service of their patients." Would you elaborate a little bit on this? I'm wondering if it is similar to Harold Searles saying that therapists need to be in touch with their own psychotic elements when trying to treat schizophrenia?

VDV: When I was growing up on the island of Cyprus my paternal grandfather used a plow pulled by animals that thrashed the wheat. “Regression” was not a scary thing for me.

KV: I think we answered a lot of this question in the response to question 6 above. In essence regression allows us to walk with the patient in their experience without our countertransference getting in the way of this. One of my teachers calls this the ability to maintain dual consciousness – a regression into the chaotic unconscious of the patient while simultaneously maintaining a rational egoic consciousness that guides the therapeutic interaction. In my opinion, this requires a certain degree of talent that probably has to do with one’s early experiences. 

I can add that I have been involved with and studied several Asian religious and philosophical systems which include meditation as part of their practice. Most meditation techniques include some form of regression. Because of this experience I have not found working with people who suffer from schizophrenia especially difficult. I agree with my dad that training is important and training specifically to do psychotherapy (not behavioral or case management) with those suffering from schizophrenia doesn’t happen much. In a sense I was fortunate to begin my career working with people suffering from schizophrenia (I wrote a blog piece on this.) I also think that working with people who suffer from personality disorders like borderline personality disorder, etc., where the patient can experience temporary psychotic states, is also helpful in learning to treat schizophrenia. 

AD: I really found your concept of the "doughnut personality" (pp.86-89) insightful. Tell us a bit more about that.

VDV: I will focus on the patients’ descriptions of their changed personality soon after the loss of their existing personality. These patients, at least for a short time, describe a new personality, which I named a “doughnut personality.” My doughnut analogy refers to patients’ experience of an exaggeratedly fearsome or exaggeratedly idealized outer layer, which is the dough of the doughnut, and a middle part that is either perceived as empty or filled with unpalatable “bad” jelly. The patients experience the outer layer as a "monster" or the opposite, an "angel" (or some similar term) according to the degree this component is saturated with the derivatives of aggression or libido.

Several of my patients going into schizophrenia described the two components of a changed personality by comparing them to a doughnut. After a while, the outer component of the dough changes; a sense of extra omnipotence (megalomania) infiltrates the dough. For example, patients now declare that they are Jesus or another prophet, the greatest musician or the best terrorist. This corresponds to classical observations on the development of “world construction fantasies.” But here I am describing a new construction in these patients’ perceived sense of their internal world. When omnipotence settles, their references to the "bad seed" or "emptiness" seem to lessen a great deal or disappear altogether.

AD: Sum up your hopes for the book, and who especially would benefit from reading it.

KV: I’ll just repeat what I said in my blog piece: The book can serve as a textbook for graduate clinical psychology students, psychiatry residents, as well as students in counseling, clinical social work students, psychiatric nurse practitioners, and other mental health graduate programs. The book is also written for the lay reader who seeks to understand more about schizophrenia, as well as the theory and process of psychoanalysis and psychoanalytic-based therapies. 

AD: Having finished this book, Schizophrenia: Science, Psychoanalysis, and Culture, what do you both have in the pipeline next?

KV: I have been working on a book about demonic possession. This will be a predominately psychoanalytic exploration that will be an expansion of a paper I published recently. I am also working on a paper looking at the latest social cognition research on schizophrenia and its implication for psychoanalysis and psychoanalytic psychotherapies with people suffering from schizophrenia. My dad and I have talked about working on a book on psychoanalytic therapy that is based on work he has done in China, which would be a fun project.