This article appeared in the Journal of Contemporary Psychotherapy, Vol 31, No. 1, Spring 2001.
Special Issue: Psychotherapy and Psychosis: What Are Promising New Developments?, pp. 21-30.
Psychoanalysis and Psychosis: Trends and Developments.
Ann-Louise S. Silver, M.D.
American Psychological Association Annual 108th Convention
Grand Hyatt Washington Hotel
Constitution Ballroom C and D
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Ann-Louise S. Silver, M.D.
Keywords: psychosis, psychoanalysis, schizophrenia, Fromm-Reichmann.
Silver is on the courtesy staff of Chestnut Lodge/CPC. She is an Adjunct Professor of Psychiatry at
Abstract: This paper presents the basic principles of insight-oriented therapy for schizophrenia, emphasizing the effectiveness of this approach: each treatment effort is a unique adventure, fueled by hopefulness in both participants. Next, it reviews the history of such treatment efforts and current tensions in the field. It presents information on the International Society for the Psychological treatments of the Schizophrenias and other psychoses (I.S.P.S.) and its current mission, to promote quality care for patients suffering from schizophrenia, to promote and facilitate research into this work, and to provide organizational support and ongoing educational programs for clinicians involved in these efforts.
Psychodynamic work with people suffering from psychoses is under siege. Our institutions, whether in the public or private sector, perhaps without exception are either shrinking or closing. “Length of stay” is itself a euphemism for a few days of rapid evaluation prior to ever-shortened “step-down programs.” Professionals working in community-based programs are pressured to increase productivity, meeting with more people less often and less intensively. Those who have stayed at the same institution for many years generally have witnessed a dramatic decrease in the their organizations’ commitment to the continuing education of their staff through in-depth case conferences, individual and group supervision, study groups, and the funding of guest speakers. Psychodynamic work is too often dismissed as outmoded, while no theory has been developed that rivals it in effectiveness or in ability to offer cohesive theory. Such work with the severely ill, which has always been under-represented, is now even considered by many as outside the standards of the community, and perhaps even harmful (Mueser & Berenbaum, 1990).
This paper delineates the basic principles of psychodynamic work with patients suffering from psychosis. It emphasizes that current opinion on the prognosis of schizophrenia is erroneously pessimistic. About one third of people suffering a psychotic breakdown are able to recover without formal professional help. Very many therapeutic dyads know that their teamwork allowed for renewed hope and the courage to strive for and succeed in healthy human development.
This paper outlines how those of us committed to such work, who have had the enormously gratifying experience of participating in recoveries, are reacting to the current health care crisis. We are organizing, collaborating creatively, and forming an increasingly effective constituency association, I.S.P.S., to be discussed later. Mental health workers in general are not as rigidly bound by guild affiliations, institutional loyalties, or by theoretical dogmas as we were in the so-called ‘good old days’. Now the professional scene is more fluid, less constricted by often arbitrarily defined boundaries. We are proving yet again the wisdom of the Chinese proverb, “Out of chaos comes opportunity.”
Those suffering from severe mental illness have never lived in a kind or gentle nation. While I promote dyadic insight-oriented work with severely ill patients, the reader should not infer that I would glorify the earlier care of the mentally ill. Beginning my psychiatric career in the early 1970s, I recall the optimism generated by community psychiatry initiatives. Meanwhile, working partly in the state hospital system, I saw patients who had been warehoused for decades on enormous barren back wards, whose psychiatrists often had responsibility for 350 or so patients, many of whom walked in cramped circles in the empty ward day room. Their weary and isolative doctors perused these patients’ charts on a yearly basis. Community initiatives offered hopes, which were partly realized, that these patients could actually return to live in their home communities. They would be rehabilitated, assisted in caring for themselves and building a future. Group therapy was popular; it too would help psychotic patients. Family therapy developed.
Meanwhile, the hugely effective parents’ organization, The National Alliance for the Mentally Ill has mounted an effective assault on theories blaming parental communications and parental psychopathology for their children’s psychotic illnesses. They combat stigma against those with mental illness. They remind us that the people who provide primary care are the families. However, much of the literature they have endorsed or supported sends a pessimistic message that those with schizophrenia suffer a genetic illness compounded by perinatal trauma producing cerebral anoxia, the resultant damage manifesting itself in adolescence or young adulthood, to be helped by medications and sheltered support. Dolnick’s book, Madness on the Couch (1998)and the recent “documentary” “Schizophrenia: Stolen Minds; Stolen Lives” illustrate these attitudes. The latter does not even mention psychotherapy in any of its forms, either in current or in past approaches.
Unfortunately, the emerging apparent consensus, often presented as fact, is that psychosis is a biologic disorder, to be managed pharmacologically. Fortunately, the newer generation of anti-psychotic agents seems significantly superior to the phenothiazines. However, the possibility that psychotic breakdown may be precipitated by intense anxiety secondary to profound inner conflict is dismissed as outmoded and somehow disproved. Students of mental health, patients and families are told to await ever more definitive treatments, now that the genome has been defined. They are referred to the NAMI literature and the Surgeon General’s Report which quote the PORT study, The Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations (Lehman & Steinwachs, 1998).
The PORT Study
Treatment Recommendation 22 states that “psychotherapy aimed at understanding
unconscious drives or getting at the psychological roots of schizophrenia is never appropriate.” (italics theirs) I believe this reflects a profound
misunderstanding of the methods and goals of insight oriented therapy. The authors of the PORT Report perhaps
imagine therapists leading patients to produce evidence of their parents’
supposed destructiveness, as if the therapist aims at allying with the patient
against one or both parents, as if shared anger at some external entity would
constitute “improvement.” I believe that
therapists generally oppose such misalliances.
Or perhaps the PORT Study authors envision an aggressive therapist
insistently enforcing a view of the patient’s inner life, as if taking on the
authoritarian tone of the patient’s
condemning and controlling hallucinated voices, but preaching a message. The
PORT Study recommendations are drawn from Scott and
Insight oriented psychotherapy
Quoting Shiobahn O’Connor, (unpublished ms.) “A psychoanalyst has trained in a discipline of thinking and in clinical technique,…a theory of the mind in which words, symptoms and behaviour have meaning, and meaning lies within the relationship rather than in the individual. The therapeutic approach is based on the belief that better understanding leads to improved communication.” In working with psychotic patients, the principles of insight oriented psychotherapy include the following:
1) Approach work with each new patient on the assumption that within every human being is a striving towards positive effectiveness and mutuality. No matter how self-absorbed and despondent a person may have become after years of defeat, confusion and isolation, there is still the probability (not merely the possibility) that over time a trusting relationship can grow.
2) Usually patients suffering from psychosis have a brittle grandiosity regarding their own magically destructive potential. One false move and someone or everyone or the entire planet will be destroyed. They thus dread the excitement accompanying feelings of hope or creativity. Therapists must respect this profound dilemma and be cautious in their pleasure when patients reveal their hidden intellectual and aesthetic capabilities. They must not provide facile reassurance that they understand the extent of this dread and magnified primitive guilt.
3) Assume that patients will test the clinician’s endurance, and will manage, through heightened self-protective sensitivity, to ferret out the clinician’s own personal vulnerabilities and defensive styles. Patients will confront the therapist’s resolve by making him or her defensive, suffering his or her own version of defeat, confusion and isolation. The greater one’s self-awareness, the more comfortable one can be in crazy situations, acknowledging one’s own crazy aspects: hence the importance of personal psychotherapy or psychoanalysis for mental health professionals.
4) Look for possibilities for playfulness and creativity. Do not stay in a hide-bound constricted office setting, protecting oneself with one's ’professional paraphernalia, but get outside and walk with the patient, both looking ahead, rather than staring each other down. Having fun together equates with working towards increasing strength and health; playfulness is not an avoidance of the work. Patients suffering a schizophrenic breakdown in adolescence usually have not mastered the latency aged task of chumship (Sullivan, 1953).
5) Do not leave all the work of talking to the patient; leave “let’s see what comes to mind” for those who choose the analytic couch. Instead, feel free to bring in your own associations, and to help the patient organize the topics under discussion. Engage in dynamically informed conversations, rather than waiting for the right time to make an interpretation (Silver, 1989, 1993, 1997.).
6) Summarize each session—the topics discussed, the conclusions reached, the plans made.
7) Encourage your patients to let you know when you have erred, and how so.
8) Abide by ethical rules of conduct. There must never be physical or sexual abuse or provocation. And just as one should never make physical demands on a patient, one should not push him or her to discuss topics mainly of interest to the therapist.
9) Meanwhile, the therapist should give the patient an opportunity to discuss past traumas: “Has anyone done things to you without your permission?” is too seldom asked, especially given the very high incidence of childhood sexual abuse in the past histories of patients suffering from psychosis (Read, 1997, 1999).
10) Treat the patient in the manner you would want to be treated. No matter how dilapidated or preoccupied the patient may seem, he or she has an acutely functioning ego, assessing the other person’s reliability and trustworthiness. Ultimately, if the therapist works at imagining what life is like for the other person, this is less tiring than keeping one’s own defensive distance. Meeting the patient’s alienation with one’s own leads to exhaustion in both parties in the defeated dyad.
debate may seem an idle distraction.
After over a decade of managed care’s assaults on inpatient and community
program reimbursements, people suffering from schizophrenia are failing to stay
connected with the places designated to provide care. They populate our jails,
are too often homeless or living in subsistence dwellings. They zip through the revolving doors of
inpatient settings that are authorized to perform only cursory evaluations
within ridiculously short authorized stays.
As The New York Times reporter Michael Winerip said, “The state
of the nation’s shattered mental-health system all but assure(s) …calamities”
(Winerip, 1999, p. 42). “In 15 years of reporting on mental health, I have
never seen the system in such disarray” (Winerip, 1999, p. 48). Mental health facilities are closing. The new owners of Chestnut Lodge, the
non-profit organization CPC Health, filed for Chapter 11 bankruptcy protection
The shorter the hospital stay, the more aggressive the pharmacologic regimen has become. Patients now are prescribed mind-numbingly complex regimens that their prescribers would have trouble keeping straight. I doubt that these psychiatrists would risk ingesting such regimens themselves for a single day. We know little about the primary effects of these medications given individually let alone in combinations. Probably we know nothing about secondary and tertiary effects. How many mental health professionals know, for example, that olanzapine, the rather new and popular anti-psychotic agent additionally prescribed to borderline and very anxious neurotic patients, is a thienobenzodiazepine, that is, a sulfurated benzodiazepine? But most importantly, if one reviews the mechanisms of action of the various psychiatric medications, one finds a listing of the neuro-transmitters affected. However, the primary effects are complex, and the secondary and tertiary effects are essentially unknown. The pharmaceutical houses, in their information presented in the Physicians’ Desk Reference essentially all admit that the drugs’ mechanisms of action remain unknown. When these are combined with anti-anxiety, anti-seizure, and anti-depressive agents, we are combining agents whose mechanisms of action are even less well defined, ultimately described simply as “tranquilizing.” Psychotic patients often ingest seven different compounds daily.
What does it
mean when we rather blindly tinker with our patients’ brain wiring, while
evincing no interest in what they are thinking or feeling? When we chronically block a neurotransmitter,
does the receiving nerve atrophy like a muscle cell held inactive too long in a
cast? What does this do to the
clinician’s humanity and dignity? What
is the countertransferential consequence of such reductionistic practice? I worry about the possibility that there is a
secret epidemic of self-medication by psychiatrists. As I hear of cases of tardive dyskinesia in
patients chronically receiving SSRI’s, I suspect that the tongue thrusting I
see in some of my colleagues may signal their self-medicated chronic
professional despair. Psychiatrists are
often tasked in clinics to work productively, seeing three or even four
patients each hour, to monitor their medications, meeting with them every month
or so. Recently I was told of a clinic
director who recommended “meds checks” on a twice yearly basis, reprimanding
the junior clinician for “over-scheduling” appointments on a monthly basis,
thus demonstrating problems with “limit-setting.” A social worker in such a clinic quoted the
psychiatrist who asked, “Why are you talking with this man? I’m giving him medications.” This doctor seemed to say that the patient is
not worth talking to, is somehow pre-verbal or perhaps sub-human. And this in Harry Stack Sullivan’s city,
where we often quote his aphorism, “We are all more simply human than otherwise.” This is the city of
I find these developments horrifying. Why at this time would psychologists want prescribing responsibilities? How do my colleagues do it, day after day, directing befuddled patients to ingest powerful concoctions that are mysterious individually and in combination even for the person writing the scripts? What about the Hippocratic Oath, to do no harm? And how has it come about that psychodynamic therapy is deemed “too dangerous” for those who have endured a psychotic storm? Where are the supporting data?
Intriguingly, the Hippocratic Oath begins “I will look upon him who shall have taught me this Art even as one of my parents. I will share my substance with him, and I will supply his necessities, if he be in need” (Guthrie, 1970, pp. 94-5). We have a responsibility not only to our patients but to our mentors as well, in this current era of quick, technical, impersonal solutions to society’s or individuals’ problems. Searles, who was my analyst until he dared to retire and move away, wrote in 1975 railing against the already strong reliance on pharmacologic agents. “[Patients with schizophrenia] have written off their fellow human beings as not kin to them, [and]… their fellow human beings have come to accept this as functionally true. If the psychoanalytic movement itself takes refuge in what I regard essentially as a phenothiazine-and-genetics flight from this problem, then the long dark night of the soul will have been ushered in, not only for these vast numbers of schizophrenic patient…but also for those relatively few psychoanalysts who are particularly interested in this field” (Searles, 1975, pp. 227-8).
Happily, we are beginning to hear of research demonstrating increasing cerebral synaptic development in psychotherapy patients of whatever diagnostic category. As such reports acquire greater validation, there will be renewed interest in the art and science of psychotherapy. Seeing, currently, is believing. Pinking up of frontal lobes over the course of effective therapy will be deemed more objective proof than the case write-up of the participant-observer (and thus biased and not monetarily disinterested) treating clinician. Additionally, Scandinavian studies by Tienari (1992), Alanen (1997 a&b), and their colleagues have shown that early psychological intervention in families where a young child has been identified as socially dysfunctional correlates with a national decreased incidence of schizophrenia as that population enters teenage and early adulthood.
presume, then, that a pro-active quest for such psychologically vulnerable
children might provide convincing data to support intensive family and
individual therapy for children and their families who are failing to meet
socio-developmental landmarks. This
probably will not happen. Just as we are
seeing an escalation of prescription of methylphenidate (Ritalin) and
fluoxetine (Prozac) in two and three year olds who act up at their day care
programs, (Zito et. al., 2000) we may soon see young children who have never
been psychotic placed on anti-psychotic medications to spare them the possibility
of breakdown. The newly formed
International Association of Early Psychosis, headed by Thomas McGlashan and
Patrick McGorry, hopes to seek out such children in the
history of psychodynamic applications to the treatment of schizophrenia, I find
that this work has been a political “hot potato” from the earliest years of
psychoanalysis in the
International Society for the Psychological treatments of the Schizophrenias
and other psychoses, ISPS, and its United States Chapter aim 1) to provide
information and collegial support for those mental health professionals working
with patients suffering from psychotic illnesses and 2) to bring issues
regarding patient care to the attention of the general mental health community
and the public and 3) to work for the improved understanding and care of those
suffering from psychosis. I.S.P.S. began
in 1956. The International Symposium on
the Psychotherapy of Schizophrenia met triennially, its participants mainly
analysts interested in applications to the psychoses. The late David Feinsilver, a Chestnut Lodge
staff member for about twenty-five years, organized its 1994 meeting in
States Chapter, ISPS-US, welcomes all mental health workers interested in the
psychoses. We held our second annual meeting
In the open
discussion of this panel, we first learned that a revision of the PORT Study is
in progress. This has mobilized the
group to increase its outreach and scholarly efforts. ISPS has organized a research task force
which will collate and review the research literature on the role of psychotherapy
in the treatment of schizophrenia.
Anthony Lehman has welcomed their collaboration in the upcoming PORT
Study revisions. I hope readers will
visit the ISPS website, www.isps.org where
they will find copies of the ISPS-US newsletters, edited by Brian Koehler,
Ph.D., and the ISPS newsletters, edited by Torleif Ruud, M.D. along with
information on membership and future meetings and formation of
As Gaetano Benedetti and Maurizio Peciccia have said (unpublished) “Biological research into …schizophrenia has…, over the last twenty years, become more and more fascinating; but psychodynamic reflection on psychopathology remains indispensable because only this forms the obligatory connection between the brain disturbance and the human condition of the patient.” If we lose a humanistic striving to understand each human being who comes to us for psychological assistance, we forego the essence of professional availability. If we objectify those who are most alienated from society, we relinquish our responsibility to build an I-Thou relationship, and encourage in its place an I-it, dehumanizing one. (Buber, 1970) While we may want to learn about the latest “scientific progress” we must guard against the dangers of scientific regression, in which participant observation devolves into objectification.
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