Psychotherapy for Schizophrenia

Continuing on with an exploration begun here, I turn now to two other works devoted to schizophrenia. I think it was Mark Ruffalo who again was helpful in recommending further resources to read about psychotherapy for patients with schizophrenia, including this book Psychotherapy of Schizophrenia: The Treatment of Choice Hardcover by Bertram P. Karon and Gary R. VandenBos (Rowman and Littlefield 2004/1981), which I discuss first before turning to Harold Searles. My approach to both books is very modest: what might I learn from them that may be useful in clinical work? 

The authors start from a premise I fully share, but which many others, alas, seem not to: "the schizophrenic patient is treatable. He or she may not be easy to treat, but is not impossible to treat" (p.33). 

Several times in the book the authors clearly seem to suggest that one cause of schizophrenia and psychosis may be massive childhood trauma, asking rhetorically (p.40) of one of the patients they see (a young man choked by his mother and repeatedly anally raped by his father), "wouldn't anyone be psychotic living such a life?" 

Language:

These authors, along with others discussed previously, and with Searles below, all seem to believe that under stress the schizophrenic patient (henceforth: SP) may revert to using language in a way more typical of earlier life, or in a dream. The SP's thinking can alternate between concrete and abstract according as which best protects against anxiety. 

If you encounter the infamous word salad and regard it as incomprehensible that is only because you've not yet made the effort to understand it! 

Hallucinations and Delusions:

Even more strongly than some of the other authors reviewed on here, these two recommend that you seek to understand hallucinations as Freud did dreams, but even more so given the motivation required to produce a dream while awake: "the hallucination has exactly the same structure as a dream" (177). Treat it as such, inviting associations and linking it to the pt's life. These can in fact be easier to interpret insofar as the pt. has worked hard to produce the hallucination.

They also advise doing something similar with delusions: look at them through the eyes of the pt. What does it mean? What sense might it make in the patient's life? Be careful before labeling or dismissing something just because it's weird. Perhaps it's a lack of understanding of how something works. And don't be afraid to test out some of them (e.g., a claim that God will end the world in 5 minutes or whatever) if it is immediately possible. 

Lack of Feedback is to be Expected:

As with Searles and others, these authors recommend that you do not expect the SP to tell you that you are helping them lest that be used against them! The SP excels at non-communication. You must go for a long time without much useful or positive feedback. Do not, however, let this inhibit you. Don't be afraid to make mistakes--this will be helpful to a psychotic patient to see you are not omnipotent. Also don't be afraid to be spontaneous and a bit free-wheeling--much better this than being stilted and overly scripted. Whatever you do, be yourself: "Your tool in effective psychotherapeutic work will always be your own personality" (139).

Defusing Threats:

The authors argue that the SP feels multiple threats on many fronts, and you need to pay attention to them and try to defuse them, some immediately, and others over the long term. Immediately: "for many schizophrenic patients it is extremely useful somewhere in the first hour to say that you will not let anyone kill him (or her)" (p.153). Ongoingly: the SP is often one whose "consciousness...is dominated by the unconscious" (142). (See below for more on this under Ego Boundaries.) 

Perhaps most paradoxically, the one threat the SP fears is the very raison d'etre for the therapy: we are told that "the patient is threatened by the possibility that the therapist will take away the psychosis" (145)!

This leads into a wider issue in which the therapist needs to reassure the SP that the former is not a taker of anything. The typical SP has felt emotionally deprived his whole life. It is therefore very important that the therapist come across as "a giver, and not a taker and to be perceived as a nonpunisher and nonpoisoner" (165). This includes requests for information or co-operation: stress that this is only to be helpful to the SP. 

What is it that you, as clinician, can give? The authors say that there are many SP "to whom the therapist need only say 'All I have to offer you is understanding, but that is a really great deal' and they react to it as if he had offered them the Holy Grail" (167).

Freedom:

Perhaps that is a bit too ungenerous, however. For you also have the ability to offer the SP freedom These authors recommend that the clinician stress from the outset the freedom to talk about anything. Nothing is taboo. While doing so, however, it is important to stress, too, that thoughts and actions, and feelings, are different and one does not necessarily lead to the other.

Anger:

These authors note that Harry Stack Sullivan and Frieda Fromm-Reichman both thought problems with anger and loneliness in the schizophrenic were much more serious than sexual problems. Anger may come out in a projected hallucination because that is the only permissible way to deal with it. 

Insults and Threats: Interpret Upward!

Later this discussion of anger comes up again as "murderous rage" (189). Talking about this or other feelings makes it easier for the SP to see that it need not lead to action. 

If, however, anger and rage do manifest in threats and insults, these authors have an intriguing approach: interpret upward. E.g., "I want to suck your cock!" = "You must really admire me!" or "I'm going to kill you!" = "you must really think I'm important enough to bother getting rid of."

The final bit of counsel I took from Karon and VandenBos is one that is, of course, generally and widely applicable in psychotherapy with patients of all sorts and conditions: to learn to tolerate not knowing. Thus they counsel that "the therapist must teach the attitude of being able to tolerate not knowing. The patient needs to learn to live with uncertainty rather than leaping to premature closure" (p.246). (This is one lesson imparted to me many years ago by Nina Coltart.)

Let us turn next to Harold Searles and his Collected Papers on Schizophrenia and Related Subjects.

I came across Searles some time back--I cannot recall exactly when or how--but immediately found his writing on counter-transference enormously helpful ("Concerning Transference and Counter-Transference"). Indeed, Searles, together with Otto Kernberg and then especially Nina Coltart remain the three most helpful people I've found so far in trying to understand and untangle counter-transferential reactions to patients. 

Perhaps even more moving to me was Searles' 1975 paper "The Patient as Therapist to His Analyst," which I only found many years after my analysis ended but which immediately helped me to understand one particular part of it in ways I could not at the time nor for many years afterwards.  

All this prolegomena is but to say I come primed to like and learn from Searles in this book on schizophrenia, and there is a lot to like and learn from--indeed, rather too much. It is, after all, a collection of previously published works, and thus runs the very real risk, much in evidence in this book, of repetitions and redundancies that strain the reader's patience. A careful editor would easily have pruned at least 25% of what is here. 

But what is here is born of an admirable willingness to try to see and understand the reality of his patients without any attempt to fit them into a Procrustean bed of theory: as he says in the introduction, "To the extent that these papers contain valid insights, they are a measure of the degree to which I have been able to relinquish any preconceptions and allow my patients to convey these insights to me" (p.10). This is not just Searles congratulating himself in advance, but it is a view confirmed by R.P. Knight in his preface, where he observes that "There is no armchair flavour in these papers, and the reader often feels that he is being permitted to be a genuine observer of clinical work," a feeling I very much had throughout (p.17).

With these preliminaries out of the way, let us turn to some of the practical observations Searles makes. Given the vast swaths of material in this book, I simply offer some selected gleanings here as they struck me as particularly insightful or clinically useful. The reader will also note that I tend to highlight where Searles is in agreement with, or at least manifests substantial overlap with, Atwood, Laing, and Bollas in my previous essay. 

Mistakes and Limitations:

Searles notes early on--an entirely appropriate way to begin--that mistakes will come up and you may in fact be able to put them to profitable use, but with the caution that the schizophrenic patient (henceforth: SP) will more readily forgive a mistake of the head than of the heart. You need to be vulnerable with them, and that is not easy to do.

Later in the book he several times makes an observation that, to my mind, applies to every patient in any condition: "One cannot formulate detailed rules which are applicable to the complex and changing conditions of a therapeutic relationship.. Nevertheless, as he continues a little later on the page, "there are several general principles which I have found to be consistently useful guides" (p.139).

One such principle is to remember the frame and humbly acknowledge what you can and cannot attempt to do--with an SP or any patient, it seems to me: "The therapist's major task is not to attempt to make up to the patient for past deprivations, but rather to help the patient to arrive at a full and guilt-free awareness of his dependency needs" (ibid). The best way to be able to do this is if "the therapist can freely accept his own human limitations, he can help the patient to relinquish his infantile omnipotence and accept his human dependency needs" (p.140). (That theme of omnipotence and its destructive potential is much observed in many of Adam Phillips' books, too, I would note in passing.) 

Dependency:

Searles argues repeatedly in much of the book that this theme of dependency may be one of the most central in schizophrenia, and may manifest itself pathologically: "Every schizophrenic possesses much self-hatred and guilt which may serve as defences against the awareness of dependency feelings" (p.116). What to do with these needs? Searles returns to this problem later and says you should neither gratify nor reject, but investigate. 

Signally, this hatred of dependency may manifest itself in what he calls "competitiveness and contempt" toward the therapist. Such feelings may also lie behind a sudden request to change therapists after months of work: you may then be on the cusp of a breakthrough which the SP finds intolerably anxiety-provoking and wants to shut down by means of removing the therapist, requiring, if the request is granted, a rewinding of the clock. As Searles puts it much later in the book, the SP is threatened by change and any idea of progress (p.461).

Compulsion to be Helpful: Watch the Counter-Transference!

Searles spends time on the anxiety aroused in the therapist whose own dependency needs are awakened in the counter-transference, which, he says, is found after a while in just about all therapists working with SPs. For both patient and therapist, these needs may be very early, almost primitive. 

For the therapist, this will show up in a "compulsion to be helpful" and a feeling of guilt that the therapist is not. This may be a disguised attempt to avoid feeling the patient's unmet dependency needs in the transference. It may also threaten the therapist's felt need for omnipotence, leading to a cycle of guilt over not meeting the patient's needs. However, Searles says in a very reassuring passage, "there is much evidence to indicate that it is this very problem with regard to infantile and early- childhood dependency needs which forms one of the strongest motivations, in therapists, for undertaking this kind of work and for persisting in it" (p.133). 

On Sexuality:

Exploring sexuality as a thread from infancy onward can "help to link otherwise patternless data and to reveal continuity" (429). 

For some, perhaps many, SPs who are precariously integrated, the experience of "being possessed by sexual lust, such as is so essential to orgiastic experience, is frighteningly similar to being possessed by--their behaviour uncontrollably governed by--introjects from one source or another" (436). As a result, the SP may live chronically under the threat of these "distorted representations of people which belong, properly speaking, to the world outside the confines of his ego, but which he experiences--insofar as he becomes aware of their presence--as having invaded his self" (467). 

Neither Too Much nor Too Little:

Don't be a literalist, and allow time for silence so that the pt. can expand upon his symbolic understanding of contents. A voracious curiosity by the therapist will threaten the patient. Thus you must finely judge how and when to probe or ask for more detail. You must be even stingier and abstinent with volunteering your own thoughts.

At the same time, however, Searles says you need to avoid smothering, permissiveness, etc. These are not helpful. Sometimes firmness is. Concretely this means that you should not accept violence or outbursts leading to it. SPs, he says, generally loathe the therapist who lets them get away with these things. 

Towards the end of the book, Searles further notes that "the schizophrenic patient needs from us not only the kind of intense emotional responsiveness which makes for comparatively dramatic clinical papers, but an equally liberal measure of neutral, and related, responses: responses of inscrutability, imperturbability, impassivity and, on many occasions, what can only be called indifference" (p.637). Earlier in the book he recounts a rather amusing case where indifference to a patient's hostility proved to be the turning point in a breakthrough. 

Ego Boundaries and Unconscious Processes:

The ego boundaries of the SP are so incomplete that they can be the recipients of massive introjections as well as initiator of massive projections: the "schizophrenic experience and behaviour consists, surprisingly frequently, in the patient's responding to other people's unconscious processes" (p.192) so that any conscious sense of self is highly porous, fragmented, and confused. It should not, therefore, surprise us when the SP manifests a delusion of being "magically 'influenced' by outside forces (radar, electricity, or what-not)," for such a delusion "is rooted partially in the fact of his responding to unconscious processes in people about him (p.192). Thus, Searles notes later, the SP is often impaired both with regard to ego integration as well as differentiation (304). 

On Communications and their Contents:

Given such fragmentary and porous ego boundaries, the SP's forms of communication often manifest the following defense mechanisms:

displacement;

projection;

introjection;

condensation;

isolation; and 

Fragmentation: skipping words, etc. this may reveal a very fragmented interior life. Searles recounts one case of a girl who, asked to read the writing on a bubble-gum wrapper, selectively skipped several words in each phrase/sentence but did so in a way and reflecting a pattern he would only later discern. 

All this often takes place in highly regressed people who have not matured to the stage of differentiating between metaphorical/symbolic and concrete thinking. As a result things are often highly disguised in part because the "archaically harsh, forbidding superego of the patient is another basic factor which helps to account for his heavily disguised and often fragmentary communications" (p.407). One way to understand such communications is to rely on your capacity to "bear intense and contrasting feelings" in both your preconscious and unconscious mind (p. 416).

Here, naturally enough, my mind returned once more to Winnicott's famous essay on "Hate in the Counter-Transference." In addition to Winnicott I also think of others (including once more Coltart as well, more recently, as Michael Karson), who counsel the therapist to know how to contain, channel, and sublimate your own aggression appropriately in service of the patient. 

Though Searles does not come out and explicitly recommend it (remember, he was writing many of these papers more than a half-century ago when analytic training was both widespread and absolutely premised upon years of an extensive personal analysis 4-5x a week) it is clear that a therapist working with SPs who has not had his or her own in-depth therapy is probably going to be of very little use here. The aggression and other bewildering emotions--the infantile dependency especially--may be overwhelming and intolerable if you have not plumbed your own depths. And even then it will not be easy-going which strongly suggests to me--though Searles does not say so--that getting good supervision here seems crucial. 

If I may interject an autobiographical note here, I would say that one of the lasting gifts of my analysis was a marked comfort with ambiguity and ambivalence, and a relatively serene awareness (to use a Jungian idiom for a moment) of the permanent nature of our shadow side. Moreover, I think--following Bollas again--that the whole notion of "madness," insofar as it has any coherent and transcendent definition at all (and I am not sure that it does), exists on a continuum and all of us move towards and away from it with some regularity. Some may find this terrifying, but I am not among them. 

One of the benefits of that analysis, as well as regular therapeutic work since then (remember that Freud recommended the therapist submit again to analysis every five years without fuss or shame--a regularly scheduled "tune-up," as it were) has been to create what I would call emotional kenosis to be at the service of the other in the consulting room. It is on this note that we read one more passage from Searles and thus take our leave from him:

Only if the forces of liberation and growth in the therapist are more powerful than those tending towards constriction, stasis, and psychological paralysis, can the patient by turn--partially through identification with the therapist--live, grow, and become progressively well (p.418). 

The Volkans on Schizophrenia

Last week I posted some thoughts on schizophrenia based on reading several books, including that of Christopher Bollas, some of whose books have been published Phoenix Publishing House. 

Now, to my great excitement and interest, Phoenix, whose praises I have previously sung, has a book coming out early in the new year co-authored by a man whom I have learned a great deal from, and whom I interviewed on here some time back: Vamik Volkan, with Kevin Volkan. They have teamed up to write Schizophrenia: Science, Psychoanalysis and Culture (Phoenix, February 2022), 240pp. 

I am very much looking forward to reading this and, if I can arrange it, to interviewing both authors. I'll keep you posted. 

About this forthcoming book we are told this: 

Two leading experts, one with a broad range of experience of institutional settings and cultures using psychodynamic, behavioral, and psychopharmacological modalities, the other an experienced psychoanalyst, bring together the complex history, causes, and treatments of schizophrenia in an easy-to-read and academically rigorous text.

Kevin Volkan and Vamık Volkan present a comprehensive study of schizophrenia using a psychoanalytic lens on the existing interdisciplinary research. Over the last seventy years, mainstream research on the causes, prevalence, and treatment of schizophrenia has greatly diverged from psychoanalytic thinking. However, the emergence of the field of neuropsychoanalysis brings hope that psychoanalytic metapsychology and clinical theory may once again provide valuable insight into understanding schizophrenia.

Psychoanalytic treatment may not be appropriate for many sufferers but psychoanalysis does provide insight to inform and improve treatment. It can also illuminate what aspects of schizophrenia are common across cultures, where they present unique characteristics, and just how cultural variations occur. For any future improvement in understanding and treating schizophrenia, the cultural underpinnings and expressions of schizophrenic illness need to be made clear.

For clinicians in the field, the authors’ aim is to deepen insight and promote the use of psychotherapy and integrated treatments, while increasing sensitivity to cultural variations in schizophrenic disease. Accordingly, this book is divided into four sections. The first gives a brief overview and outline of the mainstream understanding of schizophrenia. The second drills down to focus on general psychoanalytic ideas about schizophrenia, culminating with a focus on problems with early object relations. The third looks at how psychoanalytic treatment can be successful in some cases. The fourth and final part discusses how views of the disorder and the disorder itself are affected by culture.

The authors hope to generate insight and understanding of schizophrenic disorders which could lead to new approaches to treating and possibly preventing schizophrenia. It is a must-read for all clinicians and trainees working in the field and presents insightful ideas to anyone with an interest in the subject.

Beginning to Think about Delusions and Schizophrenia

I don't know why--my British-Canadian instincts to root for the underdog, perhaps?--but I have been haunted for a long time by stories of psychiatric patients and their abuses not just in the Soviet Gulag in the middle of the last century, but more recently, and in a supposedly "enlightened" and free country like the US--or Canada or the UK. The stories that remain with me are those of patients deemed and treated as though they are beyond reach--and this seems primarily to encompass people labeled "psychotic" or "schizophrenic." 

I have read stories of clinicians who were unwilling to simply write such people off, or consign them to subsisting in heavily drugged states in institutions, but have tried to reach, and even to heal, them, via psychotherapy. There are four such clinicians I have some familiarity with. What follows are just some initial reflections based on learnings gleaned from each of them. (I am not mounting a defense of all of them, or even each of them singly in every one of their views; nor am I conceiving of a grand theory of anything here.) 

I think the first clinician I encountered was R.D. Laing. About three years ago, reading of him somewhere and finding what I read interesting (alongside his Glaswegian heritage, which is that of my mother and maternal grandparents, who were born in and around Glasgow and lived up and down the River Clyde before emigrating to Canada), I got a copy of his semi-autobiographical Wisdom, Madness, and Folly: The Making of a Psychiatrist and read it with not just interest but real horror also, learning in there of certain techniques used less than a century ago with certain patients--e.g., insulin comas--alongside the often callous dismissal and virtual medical imprisonment of patients labeled psychotic and/or schizophrenic. 

Incidentally, numerous films and documentaries have been made about Laing, and Amazon Prime has the most recent, Mad to be Normal, which I watched with great interest. It gives no background to Laing, and only perfunctory (but damning) coverage of his shoddy treatment of his family and his many affairs and resultant children, but focuses almost entirely on the "experimental" community he founded and ran from 1965-70 in London at Kingsley Hall, a place where patients could live without judgment and enforced treatment--which was not unproblematic! 

Freud (without much experience) claimed--and everyone else seems mindlessly to have repeated--that psychosis and schizophrenia were impossible to treat with psychotherapy. Laing and a few others would show Freud to be wrong on this point. Laing was not successful with every patient, to be sure, but with enough that we must, if we are dispassionate clinicians of truly open minds weighing the findings of (loaded phrase!) an "evidence base" to consider his efforts seriously and give him credit--no matter the problems that come with some of his views, and certainly with his destructive conduct towards his children and wives. 

He writes about his clinical work in his earliest book, which I have just finished: The Divided Self: An Existential Study in Sanity and Madness. In this book, Laing writes of debts I did not know he had, including to Jock Sutherland (author of the interesting study Fairbairn's Journey into the Interior), Charles Rycroft, and the great D.W. Winnicott. 

True to his subtitle, Laing immediately dives into a claim--derived from Freud's Civilization and its Discontents--that what we call "psychosis" may be a sign of a serious split from the unbearable parts of our world, and thus have more of an external-social "cause" than an internal-biomedical one. He also notes that people locked in a psychotic state may--a theme also found, he notes, in Frieda Fromm-Reichmann (about whom see below)--be helped by the presence of a patient clinician: "since relatedness is potentially present in everyone, then he may not be wasting his time in sitting for hours with a silent catatonic who gives every evidence that he does not recognize his existence" (26). Fromm-Reichman says this, and so, as we shall see, does Christopher Bollas. 

A little later he returns to this theme, noting that the clinician must, at a minimum, make every effort to "know how the patient is experiencing himself and the world, including oneself. If one cannot understand him, one is hardly in a position to love him in any effective way" (34). 

Laing recounts an interesting claim of a patient in group therapy who felt another patient was threatening his existence and so the first patient became very argumentative precisely, he claimed, to preserve his existence. This leads Laing later in the chapter to caution (pace his earlier claim) that with some patients the therapist needs to be very careful not to extend love because it might in fact be more feared from and in the therapist than the latter's hatred. Themes of engulfment and annihilation abound here, as they will later in George Atwood, discussed below. But even more than in Atwood, Laing focuses on the necessity of a sense of autonomy in the patient, whose delusions may come about in part as a function of feeling that autonomy is under attack. 

As one comes to love a person diagnosed as schizophrenic, Laing counsels reading Kierkegaard, especially The Sickness Unto Death (which was my introduction to the Danish philosopher in high-school), saying that the clinician must first understand real despair (and Kierkegaard is an excellent guide to it) before understanding his schizophrenic patient, for the latter is nothing if not mired in despair. 

The middle section of The Divided Self is really focused on the schizoid personality, and the splitting characteristic of it. Here Laing's debts to Winnicott and Fairbairn are very clear. As we get into the final section, he deals more directly with schizophrenia, and provides in some chapters very extensive clinical material. He notes, however, something I have also found: "it is never easy to obtain an adequate account of a schizophrenic's early life. Each investigation into the life of any single schizophrenic patient is a laborious piece of original research" (179).

Laing notes something other authors have: violent fantasies and delusions, including of murder, are common in schizophrenics and reflect their sense of "having murdered their selves." He calls these delusions, but immediately says they "contain existential truth" (149).

Those in psychotic states are often known to speak what others regard as incomprehensible gibberish, but Laing notes that this is a deliberate defense mechanism: the "deliberate use of obscurity and complexity" reflects the fact that the patient is trying to scare away the doctor because the patient "is terrified of love" (163) and  wants to "avoid at all costs the possibility of being held responsible for a single coherent idea or intention" (164). 

Such are some of the gleanings from Laing which I will continue to think about. Many of them, as we will see presently, are very similar to those of George Atwood and Bollas again. 

Having finished Laing's The Divided Self, I have lined up next to read Daniel Burston's biography of Laing, The Wing of Madness: the Life and Work of R.D. Laing. (I interviewed Burston last year about his newest book.) Biographies have long been my go-to genre for bedtime reading, and I will get to this as soon as I finish another one currently underway, viz., Helen Swick Perry, Psychiatrist of America: the Life of Harry Stack Sullivan.

In addition to Laing, the other person who tried with some success to reach those often labeled as hopeless cases is Frieda Fromm-Reichmann. I have discussed her life and work here, so I will not say more about that now. She, too, remains a greatly admirable inspiration. 

Instead, let me turn to a clinician who is still alive: the retired Rutgers psychologist George Atwood, author of the recent book The Abyss of Madness. It is an enjoyable book, though the last chapter (focused entirely on 'existentialist' philosophers) seems rather tacked on and not at all integrated into the rest of the book, which mixes much good clinical sense with interesting case material. Atwood early on notes that "psychotherapy is always a dialogue between two universes, one that transforms both" (35). 

A little later in the book he comes to his titular focus, saying that "Madness is not an illness, and it is not a disorder. Madness is the abyss. It is the experience of utter annihilation" (41). Madness gains its terror, he suggests, because it raises the specter of falling into nonbeing. And madness should not be thought some rare and singular phenomenon that happens to others. Rather, Atwood suggests (and here he puts me in mind of Christopher Bollas, who has suggested that all of us cycle into and out of periods of 'madness' at some point, to greater or lesser degrees, but only a few of us get stuck there long enough to need or attract clinical attention), "the abyss is a universal possibility" (43). 

Much of the book is spent attempting to understand delusions, which at one point he regards as an attempt to restore a "lost connection to someone life-giving," a point he illustrates with an especially harrowing case study of a child devastated by paternal suicide (44). He found working with this severely delusional woman that it was necessary for him as a psychotherapist to feel and show her that he had a real "understanding of the horror" and saw his job as helping her return from the land of horrors. Doing this, he says, does not require a "diagnosis," which he sees as not just objectifying but reifying the delusion. Instead, she needed from him "validation and mirroring" (45). 

Much later in the book he returns to working out a definition of delusion, noting succinctly that it is "a belief, any belief, about the validity of which there can be no discussion" (p.99). Given that no discussion is possible, Atwood advises against making any comparisons between the delusion and "reality" for this will not help the patient. Instead, in an interesting turn of phrase earlier used in the book, such a comparison will awaken an "epistemological trauma" in the patient. (This phrase, and the way Atwood describes it, are very close to the great moral philosopher Alasdair MacIntyre's 1977 article on "Epistemological Crises, Dramatic Narrative, and the Philosophy of Science," which I have often used with my students over the years.) 

Given that delusions admit of no debate, Atwood advises that the clinician discuss these delusions as one would discuss dreams, about which he has an entire very interesting chapter. (He counsels the wisdom of something I learned both from my own experience as an analysand, and also from Nina Coltart: pay attention to the first reported dream at the outset of treatment for it may well concern "the deepest theme of the treatment that is to come" [89].)

The similarities between dreams and delusions are threefold: neither follows laws of logic and rationality; both engage in condensation and concretization; and both can, with time, fade and be forgotten. 

I confess I wish I had finished this part of Atwood's book even a day earlier, for it would have come in handy with someone whose delusions I mistakenly tried repeatedly to challenge, without any discernible effect--other than making this person acutely uncomfortable and distant which, in turn, gave rise to a counter-transference image in my mind of a ship with a damaged rudder being blown in circles in the South Atlantic.

Atwood reports additional case material, including of a patient whose delusions about coming from a "family of vampires" made a lot of sense once the patient's history was known. The sense was derived not from comparing the delusion to some notion of reality, but instead by asking what the internal meaning for the patient might be. Here as in most other cases reported, the "madness" this patient suffered was a "result of the failure of sustaining human relationships" and, usually, "disastrous trauma," sometimes visible but sometimes not (55).

What are reported as "delusions" in children, Atwood suggests, may well be potent vehicles for some truth hitherto hidden or denied. When they express themes of murder and violence this may indicate not necessarily literal violence earlier in their life, but nonetheless a strong sense of having had something precious killed.

When he turns to schizophrenia, Atwood notes that patients carrying this diagnosis "often do not experience themselves as existing. They live in a felt state of nonbeing" (58-59). As a result of this claim, Atwood at several points cautions the clinician to remember, and remind the patient, that we all live in a common world as experiencing beings, but that our experiences can and do differ. Saying such a thing to such patients helps may help them feel less estranged and threatened. 

Let us turn directly to Bollas now, almost all of whose books I have read in the last 3 years. His first book, The Shadow of the Object: Psychoanalysis of the Unthought Known remains, to my mind, perhaps his most original and important. But two others are relevant here: Catch Them Before They Fall: the Psychoanalysis of Breakdown; and then especially When the Sun Bursts: the Enigma of Schizophrenia. I just ordered the former and hope to read it over Christmas; but I have now read the latter, on schizophrenia, and it is a very rich and rewarding book indeed. Bollas writes in here with an easy and sometimes "seductive" elegance, which one does not expect in a book devoted to often such disconcerting cases and their suffering. 

Commendably, in When the Sun Bursts, he notes some limitations at the outset: the book is not a textbook on schizophrenia but is simply based on his extensive clinical work, in England and the US, going back decades. Even with this, however, he lays no claim to be an expert in schizophrenia or anything else. As he rightly puts it, "no human life is long enough to allow any clinician to claim that he or she has truly grasped the meaning of any of the 'disorders'" (2-3). 

By the time I reached the end of the book, I had come back again to this realization with renewed gratitude. We do not need, and should rightly question, anyone--no matter how distinguished--laying down the law about what Disorder X, Y, or Z means in definitive terms. Bollas eschews all of that, and it allows the reader freedom to think and to disagree. There were parts I questioned, and by the end realized that it is not necessary for me to have an over-arching and comprehensive theory that explains all psychotic phenomena, or all patients thought to be schizophrenic: instead, it is enough that this one book helped me very considerably with one case at the moment, and gratefully to receive its gifts while remaining open to and awaiting others (noted at the end of this essay).  

Bollas starts off with a blunt assertion, which, in my very limited experience so far, I fully share: "no one a psychoanalyst meets is more compelling than the schizophrenic" (p.2). Like Laing and Atwood and others, Bollas is horrified by the "throw away the key" approach we have seen in too many instances of schizophrenic diagnosis (p.8). His own approach is team-based, working with physicians and others to provide community-based care that, where possible, avoids heavy drug use and institutionalization.

He suggests that the schizophrenic might bear more than a passing resemblance to the child who finds his or her own mind more puzzling and incomprehensible than just about anything else. With time, and "good enough" parenting, they learn how to decipher parts of their mind, and to be able to bear it. But "when defenses against the complexities of the mind break down there can be a breakthrough of too much. Selves cave in" (p.8). 

At the end of the introduction, Bollas is quite insistent that if you can catch someone--especially an adolescent--at the outset of what seems to be a schizophrenic episode, then the "crucial factor that is vital to whether the person has a chance to survive and reverse the process" is that "there is someone for the person to talk to for long periods of time" over many days and weeks. If this is provided "there is a good chance that clinicians will see transformations back to non-psychotic functioning" (8-9). 

As we move into ch.1, we get some fascinating glimpses of autobiography, taking us back to Bollas' early training and work in California in the 1960s at a school with a lot of severely disturbed children. More of this emerges in ch. 3. One valuable lesson he learned then, which has remained with him all these years, is that "almost all psychotic behavior was comprehensible if one could discover the underlying logic of thought" (20). (This is a point made by Sofia Jeppson in her new article, "Psychosis and Intelligibility," Philosophy, Psychiatry, and Psychology 28 [2021]: 233--249.)

In the third chapter, Bollas speaks of "negative hallucinations" as those things that negate "the presence of objects that are present in the world around them [i.e., psychotic patients]" (45). This was a helpful phrase for me in trying to understand a particular case right now. 

Though he doesn't call them this, Bollas scatters throughout the book some "techniques" that he uses and seems to recommend. These include:

• finding out from the person what has been helpful, what "self-therapy techniques" they have successfully used to date, if any (47);
• try talking about "everyday reality" rather than inner disturbances in order to give the patient a sense of safety and anchoring (50);
• allying himself with Harold Searles, Hanna Segal, and Wilfred Bion (inter alia), Bollas advocates "listening to the free associations and unconscious communications" of the schizophrenic (50), a point he reiterates seveal times throughout the book;
• a comfortable use of silence throughout sessions (67-78).

It is in the seventh chapter that we get the story of the book's title. Bollas says that very often "those on the verge of schizophrenia may experience profound changes in their way of seeing, hearing, and thinking" (75). A little later he names these "apocalyptic moments in which the person's worldview is changed" (80). One young male patient named David in his early 20s went through a series of shocks and changes, and described them to Bollas as being the point in his life when the sun burst.  

What are some signs of such changes? Bollas lists several, including dehumanization and ritualization in which real acting persons are replaced with people playing roles. Real people are too untrustworthy and dangerous, so now they are forced into a narrative or a "play" in which they have fixed roles. The patient does so as a way of keeping people away from him. Fragmentation here is tolerable, but self-fulfillment and self-unity are not: "a self fulfilled is a self endangered" (81).

The second part of the book opens with a claim from a patient who insisted he knew things of his life before birth. I found this startling insofar as I once knew someone who made a very similar claim. Such a person creates what Bollas calls a "mythic personality" one of whose hallmarks is often a "metasexuality" marked by "frenzied connectedness" (91). Later in the chapter he returns to this, speaking of the experience of some patients in manifesting a "rapaciously deranged sexuality" (96). 

This takes us into the tenth chapter which is devoted to metasexuality. Here Bollas speaks of the schizophrenic tendency toward "sexualizing everything" in order to eradicate "the specificity of erotic fantasy life and the reality of sexual engagement with a specific other" (97). Why might a person do this? 

For Bollas, one answer might be that "the mania of sexual omnipotence aims to re-situate a failing self within a position of power" (98), but such a self is situated in a "profoundly solitary position" (101). 

Chapter 11 is devoted to "Hearing Voices," and Bollas here notes that in addition to voices, some schizophrenics also have very acute and prominent experiences of colours. He counsels that we first recognize the voices come from the inner child, and that we must also treat these voices with great respect. We should neither judge them nor critically compare them to reality, but instead simply "ask what each voice is saying and to ask for further details," confident that in doing so we will be listening to voices whose main task is to disguise and protect the self. 

Bollas says that instead of frontally challenging voices (which I have done, to utterly no avail at all!), we should both (clinician and patient) puzzle over them, asking: what can they mean? The task here is not challenge or dispute, but translation. If you ask the patient to talk about the voices, Bollas says the effect is often profound. Ask the patient to try to explain to you what the voices mean. Treat them with dignity (109). (I found this very helpful in one case after having earlier failed by challenging the delusions. It occurs to me that this is a "technique" that might admit of wider application in, e.g., our infamous political problems now with conspiracy theories about vaccines, stolen elections, etc.) 

As a psychoanalyst, Bollas notes that voices cannot free-associate and if the patient can come to see this, it may change everything. It may, in fact, provoke the kind of "epistemological crisis" we noted earlier: the supposedly all-powerful voices can do little more than repeat their claims ad nauseam, never being able to elaborate upon their points in any intellectually compelling manner. They speak for the split-off parts of the personality, but do a poor job of it, and if their poverty can be seen and accepted by the patient, this may be the beginning of the dissolution of the voices' power.

In  chs. 12 and 13 (but really throughout the book) Bollas makes excellent and very enlightening use of object relations theory to help us conceptualize what is going on in a schizophrenic mind. External objects become invested with profound meaning, speaking for and representing parts of the self that must, for several reasons, be disowned and even disdained: "Mental processes may be housed in objects that perform them." In extreme form this can result in "schizophrenic emptiness" (135-36) as the patient puts the self into various objects, retaining little to nothing for and of himself. In doing so, the patient ensures that "action defeats thinking" (142) for thinking has been made too dangerous and intolerable. The clinician who attempts to "interpret" these projections into objects is on precarious terrain here for the patient may regard such actions at tantamount to theft and react with alarm or even violence. 

A little later Bollas argues that "schizophrenics are often precocious as children, frequently speaking early and developing language skills to a very high order" (163). He does not here mention, but I naturally immediately thought of Winnicott's famous essay (which I discussed here) on precocious children, "Mind and Its Relation to the Psyche-Soma." (Bollas later in the book talks about the somatization of certain schizophrenic phenomena.) Such children, he notes, may often be "highly sensitive to colour, light, and sound" and may become experts on certain physical objects (this has been confirmed in my clinical experience.) 

As the book gathers itself towards a conclusion, Bollas circles back to make something of a plaidoyer once more for several techniques he has successfully used. 

1) Got a Comprehensive History:

He stresses repeatedly the need to get a good history, saying that places like Finland this has long been understood and practiced. Involve the family. Almost all cases reveal there was some kind of "apocalyptic" moment, some kind of abrupt shift and change that led to schizophrenic symptoms beginning. If you catch this early enough you may be able to prevent the patient from falling into a full-blown disorder. 

One additional crucial task a history does is allow for the "restoration of human temporality itself" (179) in a mind increasingly slipping far into the past or future. 

2) Narrate the Quotidian:

Ask the patient to narrate in as much detail as possible the events leading up to the painful break or moment. Do so in a way that engages the self, the I, and allows the patient to see and recover a sense of agency and subjectivity. This he says is "crucial. If he has not given up, there is time to get him to shore" (171).

Additionally, part of the task here is to re-narrate that event, to restructure it in the mind, so that it is no longer destructive, persecutory, etc. 

3) Ease the Annihilatory Defenses:

Help to decrease the anxiety about the self and begin to work towards the restoration of the subjective voice. Before (or simultaneous with) this, however, you may need to engage in the next step, often for some time. 

4) Talk to the Patient About Commonplace Matters:

They may watch you to figure out how you navigate the world, how you are not overwhelmed by the experiences that they are, and how you seem to make sense of objects in ways that differ from their use of them. Tell them about the weather, or a movie you saw, etc.

5) Ask for Examples:

How does the patient structure his mind? What heuristics does he use? What assumptions about people and the world exist? What core convictions does he have? Where are there unthought knowns? Here is where a free-association type method (and the reverie and associations it evokes in the therapist) may be useful as these things may be discovered by simply listening to and watching the patient not just talk but also interact with the environment 

6) Remember the Poets:

Bollas ends this hugely insightful and helpful book by turning to W.B. Yeats and a passage from his autobiography. This leads Bollas on to claim--without, just a few pages earlier, at all disdaining the need for psychotropic medications and hospitals in some cases--that perhaps the "poets may have more to teach us about schizophrenia than psychiatry and psychopharmacology. After all, they have learned how to descend...to the sensorial, imaginary, and symbolic in such a way as to convey our unconscious knowledge. Perhaps poets come close to the mental intersections experienced by the schizophrenic. Who knows how this happens?" (197). 

I reach the end of When the Sun Bursts: the Enigma of Schizophrenia with that familiar sense one has of having been greatly enriched by a book, but a little saddened that this enjoyable and deeply edifying conversation has come to an end--though this is a book that will repay careful reading, I am sure. Its lasting gift to me has been twofold: first, to take a disorder out of the shadows and to strip it of the fear surrounding it that I have felt as I watched it seize control of two family friends over the years; and, second, to reveal to me that this is a population I would very much like to work with. 

Next up (but not until next month, when my academic semester is over!) I hope to read Harold Searles, Harry Stack Sullivan, and Silvano Arieti (this latter introduced to me on Twitter by Mark Ruffalo, whom I thank for this kindness. He also put me on to MIchael H. Stone's useful piece, "The History of Psychoanalytic Treatment of Schizophrenia," Journal of the American Academy of Psychoanalysis 27 [1999]: 583-601.). Other suggestions of still more authors I should read are welcome in the comments.