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).