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. 

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).