A Note on Karon and Teixeria on Dynamic Therapy for Schizophrenia

That wonderful site, www.freepsychotherapybooks.org, has many riches you should peruse. Those include numerous volumes on schizophrenia. I have downloaded several such volumes and will get to them eventually.

I began with "Psychoanalytic Therapy of Schizophrenia," written by Bertram Karon and Michael Teixeria, which was originally published in 1995 as the fourth chapter of a collection edited by Jacques Barber and Paul Chrits-Christoph, Dynamic Therapies For Psychiatric Disorders (PDF). 

Some of the material in this chapter will be familiar to those who have read Psychotherapy of Schizophrenia: The Treatment of Choice by Bertram P. Karon and Gary R. VandenBos, which I discussed in detail here. In fact, I would recommend starting with just this chapter, which gives a good summary of the key points from Karon's much longer book. Let me sum up some of the insights from this chapter:

The first section is an historical review of the literature, starting with Freud, whom they describe as having had a "guarded hopefulness" about the treatment of schizophrenia. This, of course, runs contrary to the usual summary of Freud's view that schizophrenia and psychosis were beyond the help of psychoanalytic methods. 

However, having recently read his 1924 essays "Neurosis and Psychosis" and "The Loss of Reality in Neurosis and Psychosis," I do find he is indeed guardedly hopeful in both places in ways I had not previously encountered. (Both essays, and some other even more interesting ones, are collected in General Psychological Theory: Papers on Metapsychology, a used copy of which I found in an Indianapolis bookstore recently.) Karon and Teixeria report Jung as being even more hopeful, believing that it can be "completely treated and cured by psychotherapeutic means" (p.5). 

This gives rise to an historical survey, through the 1990s, of primarily American attempts at understanding the aetiology of schizophrenia as well as attempts at supporting the families of schizophrenics. We then turn to a focus on common features of the disorder, and common myths about it.

Features:

Hallucinations: These are noted as being (as others have said) wide-awake dreams, and the psychotherapist should respond to them as one does with nocturnal dreams reported by non-psychotic patients: by asking for their associations to the dream, and then offering a possible interpretation of some of the symbolism, making sure to stress that the latter is merely one's best clinical judgment and not infallible!

Delusions: Do not make the assumption that all delusions are fixed and unchanging. They are very often dynamic and significant parts can shift over time. Pay attention to the shifts! 

Interpersonal Relations: With Fairbairn these authors several times assert that schizophrenia is an interpersonal disorder and must be treated as such: "people only get sick in relationships and therefore can only get better within a relationship" (p.34). 

Goals:

The authors list a full dozen treatment goals, some of which are unique to this group of patients but many of which are common to everybody. On this latter point they share Freud's view that the two primary goals of all therapy are an increased ability to work and to love, and to enjoy doing both. 

Therapeutic Characteristics and Techniques: 

These authors share the view of others noted on here that the psychotherapist must be careful in seeking to be a giver, not a taker. And strikingly one of the most important if paradoxical areas for this to manifest itself is in the question of delusions. The patient may well be very attached to his delusions and other psychotic symptoms. Why might that be so, for it seems so odd and counter-productive. But we are reminded that these symptoms are compromise formations having considerable utility--they are "the best psychodynamic solutions the patient is capable of before treatment" (p.34).

Empathic Vision of the Terror:

It is important for the psychotherapist to make as much effort as possible to see the world as the patient sees it, and this extends perhaps above all to the delusions and hallucinations, which have meaning: "the most important thing for a therapist to remember is that every symptom of schizophrenia is meaningful and embedded in the life history of the patient. There is a difference between meaninglessness and obscure meaning" (p.37). In other words, just because the meaning is not manifest and obvious to you, there is no reason to sneer at and dismiss it as irrational nonsense!

In all this material there is to be found across the schizophrenic's vision of the world stark terror, and the psychotherapist must make every effort, repeatedly, to allay this. These authors report--as others have--that one very useful way to do this is by assuring the patients at the outset that whatever else may happen, the therapist will not allow the patient to be killed. 

Tolerating Uncertainty: 

As others have reported--including, with non-psychotic patients, Nina Coltart--the psychotherapist of psychosis and schizophrenia has to be prepared to tolerate long stretches of not knowing what exactly is happening or whether things are helping. This is not only to be expected in this line of treatment, but is itself a useful experience for the patient: 

A therapist who can tolerate uncertainty is a good model for the patient. It is useful to tell patients when they complain that therapy is making them confused, "Good. You are not sick because you are confused. You are sick because you are certain of things which may not be true" (p.39).

That last line, incidentally, bears not a little resemblance to a common theme of Adam Phillips' many books, where he notes how many of us are twisted up within narratives taken to be true that may not in fact be--or at least not wholly.

Forming the Working Alliance:

"Begin as you mean to go on" is not a bad summary for Karon and Teixeria's thoughts here. Start the intake as you would with any other patient, inquiring as to what is wrong and how you might help. This is usually enough with the schizophrenic to get them going. 

As you move into a discussion about what psychotherapy is and how you operate, they recommend that you say "All I have to offer you is understanding, but that is a really great deal" (p. 44). They also recommend you note, and repeat as necessary, that the patient has total freedom to talk about anything. Thus you need to seek to allay the common fears of such patients that the clinician will disbelieve or denigrate the patient's beliefs and visions. Equally you need to allay the fear that talking about an emotion will lead to acting on it, an especially terrifying worry for many. 

Praise What and Where You Can:

If, in your discussion of delusions as waking dreams, the patient presents an especially compelling--if manifestly unrealistic--interpretation, these authors suggest the judicious use of praise: "That is a brilliant explanation" (p.48) is one phrase they recommend. You are not thereby saying the patient's delusion or even explanation are true, but only that they might in fact be highly developed for compelling reasons that do make a lot of sense to the patient in his or her present plight. 

This, of course, is just another way of saying "Do not challenge." I have found both counsels effective in my limited experience: when I switched from challenging an elaborate delusion (which resulted in an abrupt shutting down by the patient) but instead praised it--for the patient had clearly put a lot of thought into it, down to very fine gradations of colours worn by, and highly specific grades of authority given to, some of the demons reported in the delusion--the conversation continued to flow rather fulsomely and trust was regained. 

Miller and Moyers on Effective Psychotherapists

If you're like me, you've already somewhat obsessively read at least forty-seven articles on the working alliance and an array of related topics to discover what the best therapists do. One of the reasons I started this wee blog was to share such findings as I come across them.

Over the past few years a picture has built up. It is simultaneously reassuring and terrifying that much of psychotherapy turns not on technique nor years of practice (nor still less--thankfully--on the absurd array of trademarked acronyms promising to move the sun and the other stars), but on certain gifts and characteristics that the therapist either seems to have--or not. In this, it puts me in mind once again of Anna Freud's aphorism (recorded in Robert Coles' workable biography of her) that therapists are either technicians or healers. 

This brand new book does not put it quite so bluntly, but the authors do repeatedly note that the best healers in psychotherapy seem to have certain qualities in abundance and to exercise them rather freely. This book is eminently useful in putting before the reader the latest data on what makes for a masterful therapist: Effective Psychotherapists: Clinical Skills That Improve Client Outcomes by William R. Miller and Theresa B. Moyers (Guilford Press, 2021), 213pp. 

Miller, of course, is the author of the famous work Motivational Interviewing, which generations of clinicians have heard about if not actually read. (I have read it. It was ever so slightly underwhelming.) Here he teams up with Moyers to write several very workable chapters that eschew fulgurating fireworks and convey some basic qualities and characteristics with clarity. 

Right from the get-go the authors reveal the crucial finding: already by the end of the first session, much of the outcome of therapy can be predicted. How is that possible? On what is success predicated so swiftly?

The answer will not surprise you if you are familiar with contemporary research into effective psychotherapists, who have compassion, empathy, and the ability to build a partnership with their patients in what is called the working alliance. These qualities are not time-dependent, either: a novice intern can have them and use them as or even more effectively than someone in practice for thirty years. More on all this in a moment. 

This book, Effective Psychotherapists, is divided into three unequal sections. The first, the shortest, nonetheless lays out the centrality of effective empathy as key to the working alliance. The second part, the longest, focuses on what the authors call the eight therapeutic skills you can develop and improve so that patient outcomes also improve. The third and final section contains three chapters and broadly focuses on ongoing training and future developments.

Chapter II, in the first section, is they key to the entire book. Here the authors review more than half a century of research into therapist effects to show that "the answer...is startlingly clear" to the question: what distinguishes a great therapist from the rest? In one study, that answer was almost immediately manifest: a "higher expression of therapist empathy" was found to predict "greater reduction in alcohol use" (p.10) and this could already be noted "as early as the first session" (p.11). 

They go on to note that therapists vary in their abilities and successes both between each other and with different patients: "even the best therapists are not effective with every client" (p.13). As a result, it is important not to overlook "the fit between client characteristics and therapist skills" (p.14). Nina Coltart first alerted me to this in her writing on the importance of careful intake assessment to see whether there is a good fit, and, if not, to carefully consider whom one might refer a patient to for a better fit. 

Chapter III gets into empathy in detail, considered here as "accurate empathy." The authors introduce the qualifier "accurate" to reflect the fact that a good psychotherapist will modify his or her own affect in response to what the patient is manifesting in the moment. They will also draw on their own curiosity to find out more about what the patient is feeling and experiencing. 

Accuracy may also enjoin patience upon the patient and therapist alike. That is to say, psychotherapy may be seen as an invitation to slow down to engage in Listening with the Third Ear for the voices of (in Eliot's lovely words) 

the children in the apple-tree/Not known, because not looked for

But heard, half-heard, in the stillness/Between two waves of the sea.

Quick now, here, now, always—/A condition of complete simplicity

(Costing not less than everything)

Accurate empathy's power, the authors flatly note in this chapter, is well documented now. Drawing on the results of "a meta-analysis of 82 independent" studies, it is clear that "of all the therapeutic factors that have been studied, accurate empathy has the most consistent relationship to positive client outcomes" (p.29).

Chapters IV-VI strike a very Rogerian note. Chapter IV, on Acceptance, stresses the need for psychotherapists to manifest "nonjudgmental acceptance" of everyone who comes before them. Later in the book they will note that "there is a direct relationship between your ability to extend acceptance to others...and your self-acceptance" (p.57). 

Chapter V discusses Positive Regard, calling it "a major curative factor in any approach to therapy" (p. 43). What does it look like concretely? The authors suggest that a psychotherapist shows positive regard for patients in "a commitment to their well-being and best interests" (p.44). Towards the end of the chapter they caution that this must be finely "titrated" depending on patient and circumstance. This is especially true--as I have noted in previous entries on here--with patients having psychotic or schizophrenic disorders. With them, excessive or even moderate expressions of positive regard can be taken as serious threats, provoking unexpected and unhelpful reactions. 

Chapter VI, Genuineness, may be found in such qualities as "spontaneity, humour, and vulnerability," all of which aid in building and strengthening the working alliance. 

Also in this chapter--though, alas, without citing him--they authors refer to the need, precisely to maintain your genuineness as a psychotherapist, to deal with negative feelings towards patients, which D.W. Winnicott famously called "Hate in the Counter-Transference." This remains my favourite of DWW's papers, and I have written about it in several places.  

Chapter seven, Focus, looks at the importance of setting goals that both psychotherapist and patient agree to as a way of staying on track and strengthening the working alliance. (Chapter XII will note the common finding that ruptures in the working alliance are associated with poorer outcomes for psychotherapy. But these are rarely irreparable, and the very act of openly repairing such breaches can itself strengthen the alliance new.) 

In addition, goals remind both parties that this is not just an ordinary sympathetic chat, which one can get without payment over some tea with a close friend. As my first supervisor drilled into me, the very fact that money is involved (however regrettable that may be, and however much that disturbs some of us!) means that you can never be friends with your patients. It also means that you need a treatment plan, but not one carved in stone. It can and should be revisited on a regular basis to see if we are on track, or if we need to make changes, or to consider moving towards termination--or, in a perhaps better formulation I recently came across, discontinuation of services.

Focus also helps with the ever-present and universal problem of ambivalence. The authors review the evidence to indicate how unhelpful it is to push too far and too fast for change when ambivalence has manifested itself. Your job, rather, is to help your patients talk themselves into change. For some, getting past this ambivalence is all that is necessary: the patient is then off to the races and requires little help. Others, however, may require different skills and assistance from you once they start pursuing change seriously. 

Still others may need neutrality from you, or you may deliberately choose that for a variety of reasons. This is my own default position, influenced as I am by psychoanalysis and its very high respect for patient freedom, perhaps most sharply captured by Bion's famous counsel to the psychotherapist to begin every session "without memory and desire" so as to avoid unduly pushing the patient in one direction or another. I do not find a literal and strict interpretation of Bion entirely feasible in most cases, but it remains a useful counsel of perfection as it were. 

In all cases, a fine balance must be struck: your job is not to carry patients across the finish line of change, nor to ignore their efforts to get there. And these authors also have a high respect for patient autonomy (p.78) which needs to be set alongside shared goals for "when the goals of therapy are agreed upon, progress is much more likely" (p.79). 

Chapter VIII, Hope, reflects longstanding research (going back to the famous HARP studies first published in 1961) that if the psychotherapist is hopeful, even if the patient is not or cannot be just then, such hopefulness can have a very positive effect on outcomes. Hope here extends not just to the prospects of patient improvement, but also to your own attitude towards treatment: do you yourself believe that what you are doing, the treatment you are offering, is effective and important? Hopefulness is, they say, "contagious" and in some cases you can "lend...some of yours" to your patients if they cannot find it just yet. I have done this on occasion with severely traumatized patients feeling overwhelmed by their many challenges and not seeing much light on the horizon. (Of course, like all things, your extension of hope must be finely judged so that you are not foolishly prattling on about the hope of a total, immediate, and facile "recovery" to someone who has been, say, a heavy addict for thirty years, or a lifelong victim of sexual abuse.) 

Additional techniques here include asking patients to narrate past experiences where they had some success over a particular challenge. Another is to focus on their strengths. 

Hope for change can be seriously undermined, the authors note at the conclusion of this chapter, by a waiting list, for the research indicates that patients do exactly that: sit and wait. They do not, in other words, get started on any changes. This can be demoralizing and deflating of their discipline and desire to get started on change. For this reason, then, I here recall the words of an addictions psychologist I knew: you or your staff who answer the phones (e-mails, etc.) from people seeking services should give the warmest possible response with the utmost dispatch--within 24 hours at the most. People have often taken weeks, months, sometimes years to work up the courage to call for help, and you need to meet them at that moment wherever possible. Do not leave them hanging for days or weeks, even if you are very busy and cannot fit them in at that moment. 

Chapter IX, Evocation, focuses on a skill the authors see as uncommon and infrequently developed in the training of therapists. They do so based on the conviction that patient characteristics play a huge role in the success of therapy just as those of the clinician do. So the task of the therapist here is to evoke in the patient his or her own skills at self-healing. This is a position that starts from the assumption that the patient is in not just a state of deficit but also a position of having riches to offer they may not be aware of or able to access just yet. To access these riches, they may need your curiosity as a clinician to call them forth.

One way to help patients do this is summed up as O.A.R.S.: Open Questions, Affirmation, Reflection, and Summary. All this is to evoke that "change talk" that Miller first made famous in Motivational Interviewing. 

Chapter X, Offering Information and Advice, is one that, admittedly, I read with the greatest resistance, especially when flatly told by these authors that "Advising is a part of your job" (p.110). I make it very clear to my patients that I am not in the advice business. I think offering advice almost always infantilizing and counter-productive, and I loathe doing it. I am never so much a student of Erich Fromm as here in wanting people to live out their own freedom without fear and to find their own way. 

That said, these authors point to an example that I have myself done: recommending reading material. I once had a patient who for several months was manifesting great ambivalence, bordering on anxiety, between two very different career paths, each of which I thought she was romanticizing unduly while being very anxious about what she would miss in choosing one over another. So when she asked for something to read about this my mind shot immediately to Adam Phillips' Missing Out: In Praise of the Unlived Life, which I tried to mention as neutrally as possible so that my great enthusiasm for all of Phillips' works would not come out unduly. I made it clear--I think!--that I was simply reflecting how valuable I have found Phillips, and not telling her that she had to read him. But she turned up at the next session with the book under her arm, half of it read and heavily underlined in parts, and we had two or three sessions profitably discussing the book.

Chapter XI, The Far Side of Complexity, is a bit of a jumble as the authors seem clearly at pains to take avoid taking a clear stand on things bolder clinicians like Coltart have just come out and forthrightly spoken of as "faith; faith in ourselves and in this strange process which we daily create with our patients." For Miller and Moyers, they dance around such seemingly "spiritual" or "theological" language by invoking slogans like "simplicity on the far side of complexity" and talking about transcendence and shoveling in a few gratuitous bits of Buddhism that have too little context or elaboration to be useful. 

Coltart is again much better here in capturing this simplicity-within-complexity dynamic in describing the therapist as engaged in

sharply focusing, and scanning; complex involvement in feelings, and cool observation of them; close attention to the patient, and close attention to ourselves; distinguishing our own true feelings from subtle projections into us; communicating insight clearly, yet not imposing it; drawing constantly on resources of knowledge, yet being ready to know nothing for long periods; willing the best for our patients and ourselves, yet abandoning memory and desire; a kind of tolerant steadiness which holds us while we make innumerable, minute moral decisions, yet steering clear of being judgmental (Slouching Towards Bethlehem, p.119). 

Chapter XII stands at the start of Part III of Effective Psychotherapists, which, with the exception of the previous chapter, has so far been written with wonderful and admirable cogency and clarity, making this an ideal text for undergraduates or graduates alike. (I am very warmly recommending it to my students next semester in my Introduction to Counselling course.) 

This chapter, Developing Expertise, records the startling but simultaneously reassuring and "widely replicated finding that therapists' years of experience are unrelated to their actual expertise" (p.127). Left unsaid here is a tempting line of thought I might have developed about the need for more careful screening of students into training programs to see if some of the attributes discussed earlier in this book are in evidence or not. 

Also left unsaid here is any discussion about the centrality of the psychotherapist's own psychotherapy. Raising this point seems to generate a lot of controversy and resistance among some, for reasons which are not clear to me. I regard it as de rigueur that a psychotherapist must have done their own in-depth work. I know I could never do this myself without having spent years on the analytic couch, as I have done in three separate periods. Freud was right, in one of the last essays he wrote, "Analysis Terminable and Interminable," in seeing that one's own analytic therapy offers both skills and insights which are "not ceasing when it ends." But the gains may be limited, which is why he rightly goes on, later in that essay, to call for the therapist "periodically--at intervals of five years or so--[to] submit himself to analysis once more, without feeling ashamed of taking this step." 

In addition to one's own semi-regular therapy, Miller and Moyers argue there are things a clinician can do to improve in certain areas or to acquire or reinforce certain skills. These they treat under the heading of "deliberate practice" which has two components: some skill you very consciously focus on developing, and some supervision of it or feedback about it you also consciously cultivate and seek out.

The book concludes with Chapters XIII and XIV, which may be of some limited interest to academics teaching courses in psychotherapy and counseling, including courses in skills and techniques. 

Overall, the book is a very useful and up-to-date summary of what we know about Effective Psychotherapists and their clinical skills, and it is written in a way that allows its summaries of relevant and recent research to be made easily accessible to general readers, students, and scholars alike. 

Self Psychology and Psychosis

While looking for something else--as so often happens--I stumbled upon this useful little book by Ira Steinman and David Garfield: Self Psychology and Psychosis : The Development of the Self During Intensive Psychotherapy of Schizophrenia and Other Psychoses (Routledge, 2019), 192pp.  

Steinman (whose website is here, with some excerpts of his writing) trained with R.D. Laing and for a time worked at Chestnut Lodge. Garfield is also a psychiatrist and psychoanalyst, recently retired from the Chicago Psychoanalytic Institute. Both have teamed up to write a book that usefully agrees with other similar treatments, including those of Atwood and Bollas, already noted on here, and then especially with Bion in particular. At the same time, however, this jointly authored effort also differs from other treatments in bringing to bear aspects of self-psychology, most of them drawn from Heinz Kohut. 

I have several of Kohut's books, and have struggled to profit by them. The fellowship I did at the Chicago Psychoanalytic Institute in 2018-2019 helped break down some of his thought and make it somewhat more clear; but one always feels the need to keep a glossary close at hand because he uses, in some cases, ordinary language in quite singular ways and it is easy to misunderstand him when he does this. 

Since I'm mentioning him, let me also put in a plug here for Charles Strozier's excellent biography, Heinz Kohut: The Making of a Psychoanalyst, which I read several years ago. I owe several intellectual debts to Strozier (a Harvard-trained historian as well as practicing psychoanalyst), who was very kind in sending me drafts of papers and reviewing some of mine. It was also he who introduced me to the invaluable work of Vamik Volkan, whom I have previously interviewed on here, and whom I will again interview early next year when his new book Schizophrenia: Science, Psychoanalysis, and Culture appears, jointly authored with his son. 

But back to Steinman and Garfield, and their useful contribution to the literature. They begin with a few caveats we would do well to recall:

Some Initial Caveats and Requirements:

First, psychosis is not a unitary phenomena. Patients still retain all their uniqueness here as elsewhere. So do not make lazy generalizations, assuming that you've "seen it all before." Equally, do not assume that some successful piece of work in the past may stay in the past, or some issue you feel the patient has overcome will not re-appear. Here both authors remind us of the basic principle Freud first articulated: in the unconscious mind, there is no time. And schizophrenia is especially adept at destroying a coherent sense of temporality. 

Second, at every stage as you are working with these patients, the key thing is hope. If you can confidently but carefully cultivate some hope, that will aid both the working alliance and also the overall progress and prospects of the therapy. 

Learning to Speak Schizophrenese: 

These two authors echo what others have said about making the effort to understand the patient's use of language and symbolism, and impairments to the same: "One extremely important factor in my work with very disturbed people is the importance of understanding a patient’s symbolism, as contained in hallucinations and delusions. A good working alliance aids in helping the person make sense of confusion and distortions of reality. The closer one gets to the 'lost heart of the self' the easier it is to make sense of previously indecipherable and upsetting material" (p.xxi; the internal reference is to Guntrip).

Whereas some clinicians have dismissed, often patronizingly (as I have heard directly in one consult I was part of years ago) the schizophrenic patient's language and symbolism as the notorious "word salad," these authors insist--rightly in my view--that "speaking schizophrenese, making sense of psychotic productions, is the glue that makes therapy with the most disturbed work" (p.xxi). Neither here nor at any other point in the book do they downplay how difficult this can be in some cases, and how much patience is required by the psychotherapist over the long haul. But the therapist is helped by understanding that hallucinations and delusions are like a loud-hailer or sound amplifier for the self, perhaps especially the fragmented and painful parts that are projectively identified with external objects. 

How could one go about understanding those objects and their meaning? How could one begin to enter into a world that seems fragmented, confused and confusing, perhaps even hostile and bewildering? Here they turn immediately to the founder of self-psychology in this country: "Kohut suggested instead that through 'vicarious introspection' the analyst must look inside and find 'a taste' of what the patient is experiencing" (p.xxv) This is very similar to something Christopher Bollas has said about seeking to find the lost patient, and discovering that something of him is hiding within the therapist.  

The Paradoxical Protections Offered by Delusions and Rages:

For Kohut destructiveness and rage are the products of a disintegrating self that has sustained some injury. They thus have quite a "thick" meaning, as it were, and one must work carefully in trying to disarm the forces of destruction and rage without leaving the patient feeling overwhelmingly vulnerably exposed. Delusions are "both fragile and rigid" (p.104). Their rigidity has been helpful in giving even a minimal sense of security to the patient and holding back a totalized experience of fragmentation. Thus these authors recognize later in the book that "a delusional system is a compensatory structure that prevents fragmentation" (p.98).

In addition, delusions and fantasies have a self-protective, self-soothing or self-enhancing purpose and taking them away may have serious unintended consequences. Frontal attacks--and this seems a point of universal consensus so far in what I have read, which admittedly is not much yet--on delusions are a complete waste of time, and may in fact backfire. It is within the working alliance, and the transference, that you may begin to help someone see that their views are mistaken. As they come to mentalize more, and to understand things from a second-person perspective, the hold delusions have may begin to lessen. 

One tip the authors offer here is to take a history from the delusional figure. E.g., in one fascinating case they discuss, a woman believed she received messages from a "Good Angel.” Alright. So ask that angel for its history, then. How did it grow and develop, at what point, and in what circumstances? What purpose is it trying to fulfil? As you seek out all this material, gaps ("epistemological trauma," in Atwood's words, discussed here) may emerge in the history, or purpose, or message, that can be usefully wedged between the patient and the delusion. 

A great deal of case material makes up the book, and I will not annotate that here. I would, however, encourage interested readers to peruse it for themselves.

Instead let me turn to an earlier work of just one author, Ira Steinman, and his 2009 book from Karnac in London, Treating the "Untreatable": Healing in the Realms of Madness.

Steinman beings autobiographically, but with a searing self-criticism that extends and applies to his guild, as well. Here and elsewhere he will criticize American psychiatry, as he already telegraphs in his title and its dismissive labeling of schizophrenics as "untreatable." He tackles this bogus charge at the outset of the book: 

I have found over the last 40 years of psychiatric practice, however, that a number of these allegedly 'unresponsive' and 'untreatable' severely disturbed patients, diagnosed as suffering from schizophrenia, paranoid delusional disorder and multiple personality disorder, have responded to an in-depth exploratory psychodynamic psychotherapy. In a number of cases, antipsychotic medication has been titrated down and stopped (p.xiv).

He returns to the self-criticism in the last chapter, which frankly and critically admits US psychiatry is to blame for abandoning schizophrenic patients and psychotics and regarding them as untreatable, and thus justifying itself in not treating them at all. Such criticism is advanced without any self-righteousness. If anything, Steinman is at pains to stress that there was and is nothing fancy or heroic about what he did and does: he simply offers plain old psychotherapy to help patients find meaning behind terrifying voices, hallucinations, etc. And space to begin to integrate and defragment. 

After some introductory material, the book is largely made up of case material drawn from about 12 schizophrenic or delusional patients. 

That introductory material includes several useful bits of advice: 

Dreams:

Like numerous other authors (perhaps none so clearly and forcefully as the psychiatrist Andrew Lotterman in this excellent and useful article), Steinman notes the importance of one part of the counter-transference in particular: your own dreams. He suggests that useful dreams you have about your patient may be judiciously shared: patients tend to like that you think of them outside sessions, and these dreams can often illuminate certain things or open up good lines of exploration. 

Patience and Hope:

Again we hear sounded the refrain that the patient isn't the only one who needs patience! The clinician must keep in mind that, in most cases, "the period of psychotherapy aimed at helping the patient overcome a schizophrenic or delusional orientation will be a long and arduous one, with change measured in infinitesimally small increments. Long intervals of seeming stasis must be tolerated by both patient and therapist in the face of what may appear to be gridlock, if the process is to bear fruit" (p.8).

Steinman firmly believes an intensive psychodynamic approach works, and his book is evidence of that. The overall task consists, in part, of proving Freud right: Where id was, there shall ego be. That is all the more important in schizophrenic patients whose ego seems barely intact and needs a great deal of clarifying and strengthening. And such tasks, Steinman notes rather scornfully, cannot be done, and are not done, by so-called supportive psychotherapy, which he regards as often useless: it doesn't touch the underlying psychic conflicts and pain, leaving the delusions fresh untouched terrain to ravage and revisit. 

The Nature and Purpose of Delusions:

Speaking of delusions, he sees that they are usually a sign of great pain and terror. It is easier to believe you are Jesus, or to live in fear of Mafia, than acknowledge internal pain and terror that both delusions mask. Thus delusions have a function, and often he sees that as being "a creative compromise," albeit often unrecognized as such (p.3). This makes giving up delusions hard if it means being in contact with a painful reality.

Methods:

How does one go about doing that--beginning to move past delusions? Here as elsewhere the alliance is key; the setting is also important as a holding environment where, bit by bit, patients may feel safe and supported and open up. Steinman elaborates, however, noting that "the patient’s trust in the therapist and in his reliability as a consistent object, although extremely important, is not sufficient by itself to help the patient through the morass of delusions and psychosis......Clinical improvement occurred only when a more interpretive, psychoanalytically oriented approach was attempted" (p.26). So do not just hold and soothe, but work! 

More concretely he offers us the following methods:

1) Get a good history! Find out when psychotic material began. Also, here or later, take a history from the delusional figure. E.g., Judith's Good Angel: what was the angel saying, why, and when did it start? Can the angel answer unexpected questions put to it, or does the angel begin to fall apart? 

2) See what meaning this material--delusions, etc.--has. This goes to the book's fundamental "conviction that delusional and psychotic behaviour not only had unconscious meaning to the patient but could be made understandable to the patient in the form of a healing exploratory dynamic psychotherapy, in conjunction with antipsychotic medication used in a judicious fashion" (p.185).

This latter point bears underscoring: Steinman, and virtually everybody else I have read so far, is not against the judicious use of anti-psychotics--though he argues very strongly that it is possible for these to be titrated downward for some, and in others eventually to be discontinued entirely without relapse of symptoms. 

3) Reconstruct the feelings behind the origins of the psychosis, delusion, etc. 

4) Slowly move towards the hurt, undefended lost heart and inner core

5) Let them sit with their rage, hurt, abandonment.

6) Transference reactions not only happen, but are usually more extreme. This, in itself, can be revelatory to patients, as they can gradually come to see their reaction is disproportionate, and to begin to wonder why. One memorable example he gives here is that his own calm and containing presence sometimes provoked rage in those who had no such thing and were jealous: they tried to up the ante with violence towards him. 

A Quick Word on Self-Care:

You must have time and plenty of interests away from psychotic patients. (I have only two patients at present with psychotic symptoms, and I enjoy them hugely, but I have realized that--as with victims of sex abuse, whom I also treat--I could not have a full practice devoted just to them for it would become exhausting and overwhelming.)

Finally, I would note that Treating the "Untreatable" contains an Appendix that sums up lots of international studies on recovery rates from schizophrenia. Keep this close to hand for those impertinently crowing about how their preferred treatment is "evidence-based" while psychodynamic psychotherapy is not. 

W.R. Bion's Second Thoughts on Schizophrenia

Introduction: 

When I was discovering the Middle/Independent and object relations schools in Her Majesty's United Kingdom in the 1990s, Bion's name came up several times. Both then and since I tried, in an admittedly desultory way, to read a bit of him, but finding the experience infelicitous, did not persist in my attempts.

Recently, however, I have made some in-roads with him, and it is through his papers on schizophrenia, most of them collected in Second Thoughts, that I have found some material to latch onto as it were. My method in reading this book was admittedly rough: I ransacked it for only such material as struck me as being clinically useful and broadly in accord with what I have previously read, much of it noted on here already.

The chapters in this book that focus on schizophrenia draw their material from his work with six patients. Bion says he did not depart from analytic technique, taking note of positive and negative transference (about which more presently). 

Bion notes that Melanie Klein's work plays a central part in his attempt to understand schizophrenia, especially his insistence that the schizophrenic is making constant use of projective identification and splitting to navigate the world. This leads him to claim, early in the book, that "the peculiarity of the schizophrenic's object relations is the outstanding feature of schizophrenia" (p.23). 

Centrality (if not Singularity) of the Counter-Transference: 

Bion also notes  that "counter-transference has to play an important part in analysis of the schizophrenic" (p.24). Bion is writing this well over half a century ago, but his point has been given even stronger emphasis in a recent and fascinating essay I read tonight by the Columbia psychiatrist Andrew C. Lotterman ("Psychotherapy Techniques for Patients Diagnosed with Schizophrenia," American Journal of Psychotherapy 70 [2016]), who insists on the absolutely irreplaceable value of the counter-transference, saying that sometimes this may be the only tool the therapist has at his disposal for understanding fragmented speech, hallucinations, and other psychotic manifestations. Lotterman:

In many cases, the countertransference is the only place where some of the patient’s crucial emotions and fantasies will appear in the treatment. The patient often projects or induces these experiences into the therapist to rid himself of the burden of feeling them, and of the work of becoming conscious of them by capturing them in words or images.

Frequency of Splitting: 

Back to Bion, and so to Klein, on the centrality of splitting in the schizophrenic: he notes that they may often try to split the therapist in a variety of ways you might not appreciate for some time. Some examples: to overstimulate and to make you so drowsy you fall asleep; to ask two incompatible demands of you (longer and shorter sessions). Insofar as the patient can move from splitting to the depressive position, Bion says, we may see this as a sign of progress and increasing health. But the patient may fight this and return to a more primitive position precisely because of the inability to deal with the psychic pain of being in touch with 'reality' (which depresses us all, psychotic and non-psychotic alike!). 

It is not just that objects are split, but Bion insists that many objects are often pulverized into fragments, and then compressed and agglomerated: they cannot be synthesized. Insertion of them into the patient's mind is felt to be violation and an assault.

Later on Bion returns to this, advising the psychotherapist that you not allow yourself to be confused in thinking too high: that when a patient mentions and attacks an object, they have the full object clearly in mind. They do not. You, the clinician, would assume this, but in reality the patient does not have the full object clearly in mind. They are attacking only fragments, residues, etc. They resent these objects and do not have sufficient curiosity to investigate and know them in their fullness. 

Projective Identification:

For Klein, splitting is a key part of the phenomenon of projective identification, of which Bion makes much in this book. He says that for the schizophrenic, projective identification is widespread and key; it replaces repression. Ordinarily objects that are unpleasant may be repressed but the schizophrenic cannot do this and so the objects are split off and identified in particles in and with other objects. 

In turn, this makes the introjection of those objects impossible. One consequence of this is that excessive projective identification at an early stage prevents "smooth introjection and assimilation of sense impressions and so denies the personality a firm base on which the inception of pre-verbal thought can proceed" (p.61). 

Attacks on Linking:

I have previously read Bion's essay, "Attacks on Linking," but did not, at the time, pay attention to the fact that it was so focused on psychosis and schizophrenia. But now, having read it in this context, and in light of other recent reading, this chapter makes a very great deal more sense.

The patient attacks anything that feels like a link between objects. They may even attack links to such fragments of feelings they feel, or need to feel: thus they can hate their hatred, etc.

One helpful way to begin to notice these attacks on linking, Bion says, is the frequency with which they often resort to "it seems" language rather than such firmer declaratives as "it is" or "I think." 

Because it is difficult for the schizophrenic to accept links, Bion strongly advises (and others do, as we have seen) that the therapist avoid why questions: the patient will have little understanding of causation, those links having been severed also. So do not ask why or try to induce the patient to offer some speculation on how A might have caused B.

This lack of understanding of causation, on a much larger and 'structural' scale, comes up later in the book when Bion says we must not expect to meet material that has been filtered and mediated by the patient's personality:

Psycho-analysis of the psychotic personality thus has a quality which makes it so different from the analysis of the non-psychotic personality. Conversely, the relationship with external reality undergoes a transformation parallel to the relationship with psychic reality which lacks an intervening (or "interceding") model. There is no "personality" intervening between the psycho- analyst and the "unconscious" (p.147).

A Lack of Dreams:

Bion seems to accept--as other authors noted on here also do--that hallucinations and delusions are, and are to be discussed and treated as, wide-awake dreams. Their prevalence may explain the striking absence of actual nocturnal dreams. In some schizophrenic people, conventional nocturnal dreams might well be found to be rare: "The psychotic patient appears to have no dreams, or at least not to report any, until comparatively late in the analysis" (p.98). 

Primitive Disaster and Ever-Shifting Psychotherapy:

Bion engages in some useful repurposing of Freud's famous analogy, saying that "I suggested that Freud's analogy of an archaeological investigation with a psycho-analysis was helpful if it were considered that we were exposing evidence not so much of a primitive civilization as of a primitive disaster"(p.101). The problem, he elaborates, with the metaphor of an archaeological dig site is that it presupposes a static and settled site, but an analysis/therapy is no such thing: it is a moving thing of many parts. (A realization of this lies behind his strong deprecation of the therapist entering a session with memory or desire, which may weigh down and hold the session back from moving in the direction it wishes.)

In particular terms, Bion notes that this is true of the use to which hallucinations are put: such use is often constantly changing so one must not assume a once-and-for all grasp of the hallucinations and their purpose in the patient's life.  

In general, and overall Bion advises--as many others do--that the therapist prepare for lots of ambivalence: the patient may come, eventually in his own way, to manifest some gratitude that the therapy gives occasion for or provides things the pt. was denied growing up, but that same patient will also manifest resentment/hostility, also directed toward you, that he was deprived in the first place. 

So you are--in Kleinian terms--both the good and bad breast. This may well arouse in you a regular feeling of being uncertain and confused, as the patient will seek to attack your peace of mind, and any links in your mind between the work you are attempting and the changes you hope to see. Others I have read all make note of this, and advise that the clinician must be very comfortable with going for long stretches where things do not seem clear. 

Here is where Coltart's words come back to mind for me when she advocates that we have "faith; faith in ourselves and in this strange process which we daily create with our patients." Such faith will carry us through the long stretches of fog during which we long, in Newman's felicitous words, to see the "kindly light" but are denied it, instead being forced to accept "one step enough for me." 

To preserve and protect that faith, and even more the freedom of the patient, Bion, at the end of the book, it seems to me, goes on what I regard as a radical Fromm-like tear about absolutely respecting the freedom of all your patients, the schizophrenics especially. This requires your getting rid of any desire for "cure" or "improvements" or "results" in your patients (the neurotics as well as psychotics). If you have no such desires, then there is one less thing for the psychotic patient to attack. Moreover, of course, Bion thinks having those desires--whether they are attacked or not--is a hindrance to the patient and an impingement on her freedom. In this he is joined by other members of the British school, including Nina Coltart, who also strongly disdains the language of cure. 

Overall, for those undertaking this difficult and lengthy work with these types of patients, Bion's book offers some helpful counsel encouraging freedom and creativity: "The psycho-analyst who undertakes a schizophrenic analysis undergoes an experience for which he must improvise and adapt the mental apparatus he requires" (p.146).