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.