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.
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.
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