Monday, February 2, 2009
Psychoanalysis and Psychosis: Trends and Developments
Abstract: This paper presents the basic principles of insight-oriented therapy for schizophrenia, emphasizing the effectiveness of this approach: each treatment effort is a unique adventure, fueled by hopefulness in both participants. Next, it reviews the history of such treatment efforts and current tensions in the field. It presents information on the International Society for the Psychological treatments of the Schizophrenias and other psychoses (I.S.P.S.) and its current mission, to promote quality care for patients suffering from schizophrenia, to promote and facilitate research into this work, and to provide organizational support and ongoing educational programs for clinicians involved in these efforts.
Psychodynamic work with people suffering from psychoses is under siege. Our institutions, whether in the public or private sector, perhaps without exception are either shrinking or closing. “Length of stay” is itself a euphemism for a few days of rapid evaluation prior to ever-shortened “step-down programs.” Professionals working in community-based programs are pressured to increase productivity, meeting with more people less often and less intensively. Those who have stayed at the same institution for many years generally have witnessed a dramatic decrease in the their organizations’ commitment to the continuing education of their staff through in-depth case conferences, individual and group supervision, study groups, and the funding of guest speakers. Psychodynamic work is too often dismissed as outmoded, while no theory has been developed that rivals it in effectiveness or in ability to offer cohesive theory. Such work with the severely ill, which has always been under-represented, is now even considered by many as outside the standards of the community, and perhaps even harmful.
This paper delineates the basic principles of psychodynamic work with patients suffering from psychosis. It emphasizes that current opinion on the prognosis of schizophrenia is erroneously pessimistic. About one third of people suffering a psychotic breakdown are able to recover without formal professional help. Very many therapeutic dyads know that their teamwork allowed for renewed hope and the courage to strive for and succeed in healthy human development.
This paper outlines how those of us committed to such work, who have had the enormously gratifying experience of participating in recoveries, are reacting to the current health care crisis. We are organizing, collaborating creatively, and forming an increasingly effective constituency association, I.S.P.S., to be discussed later. Mental health workers in general are not as rigidly bound by guild affiliations, institutional loyalties, or by theoretical dogmas as we were in the so-called ‘good old days’. Now the professional scene is more fluid, less constricted by often arbitrarily defined boundaries. We are proving yet again the wisdom of the Chinese proverb, “Out of chaos comes opportunity.”
Those suffering from severe mental illness have never lived in a kind or gentle nation. While I promote dyadic insight-oriented work with severely ill patients, the reader should not infer that I would glorify the earlier care of the mentally ill. Beginning my psychiatric career in the early 1970s, I recall the optimism generated by community psychiatry initiatives. Meanwhile, working partly in the state hospital system, I saw patients who had been warehoused for decades on enormous barren back wards, whose psychiatrists often had responsibility for 350 or so patients, many of whom walked in cramped circles in the empty ward day room. Their weary and isolative doctors perused these patients’ charts on a yearly basis. Community initiatives offered hopes, which were partly realized, that these patients could actually return to live in their home communities. They would be rehabilitated, assisted in caring for themselves and building a future. Group therapy was popular; it too would help psychotic patients. Family therapy developed.
Meanwhile, the hugely effective parents’ organization, The National Alliance for the Mentally Ill has mounted an effective assault on theories blaming parental communications and parental psychopathology for their children’s psychotic illnesses. They combat stigma against those with mental illness. They remind us that the people who provide primary care are the families. However, much of the literature they have endorsed or supported sends a pessimistic message that those with schizophrenia suffer a genetic illness compounded by perinatal trauma producing cerebral anoxia, the resultant damage manifesting itself in adolescence or young adulthood, to be helped by medications and sheltered support. Dolnick’s book, Madness on the Couch and the recent “documentary” “Schizophrenia: Stolen Minds; Stolen Lives” illustrate these attitudes. The latter does not even mention psychotherapy in any of its forms, either in current or in past approaches.
Unfortunately, the emerging apparent consensus, often presented as fact, is that psychosis is a biologic disorder, to be managed pharmacologically. Fortunately, the newer generation of anti-psychotic agents seems significantly superior to the phenothiazines. However, the possibility that psychotic breakdown may be precipitated by intense anxiety secondary to profound inner conflict is dismissed as outmoded and somehow disproved. Students of mental health, patients and families are told to await ever more definitive treatments, now that the genome has been defined. They are referred to the NAMI literature and the Surgeon General’s Report which quote the PORT study, The Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations.
The PORT Study Treatment Recommendation 22 states that “psychotherapy aimed at understanding unconscious drives or getting at the psychological roots of schizophrenia is never appropriate.” (Italics theirs) I believe this reflects a profound misunderstanding of the methods and goals of insight oriented therapy. The authors of the PORT Report perhaps imagine therapists leading patients to produce evidence of their parents’ supposed destructiveness, as if the therapist aims at allying with the patient against one or both parents, as if shared anger at some external entity would constitute “improvement.” I believe that therapists generally oppose such misalliances. Or perhaps the PORT Study authors envision an aggressive therapist insistently enforcing a view of the patient’s inner life, as if taking on the authoritarian tone of the patient’s condemning and controlling hallucinated voices, but preaching a message.
The PORT Study recommendations are drawn from Scott and Dixon’s 1995 paper, “Psychological interventions for schizophrenia,” not itself a meta-analysis of past studies, but rather an incomplete literature review. It states, “…individual psychotherapy historically connotes either dynamically oriented psychotherapy, which typically seeks to increase insight, or supportive psychotherapy, which typically seeks to build ego strength.” The distinction itself lacks substance. How can one increase insight independent of ego strength? How can one’s ego become stronger without an accompanying increase in awareness of one’s patterns of interaction and of reaction, of one’s strengths and weakness, and one’s ways of coping with anxiety?
Insight oriented psychotherapy
Quoting Shiobahn O’Connor, (unpublished ms.) “A psychoanalyst has trained in a discipline of thinking and in clinical technique,…a theory of the mind in which words, symptoms and behaviour have meaning, and meaning lies within the relationship rather than in the individual. The therapeutic approach is based on the belief that better understanding leads to improved communication.” In working with psychotic patients, the principles of insight oriented psychotherapy include the following:
1) Approach work with each new patient on the assumption that within every human being is a striving towards positive effectiveness and mutuality. No matter how self-absorbed and despondent a person may have become after years of defeat, confusion and isolation, there is still the probability (not merely the possibility) that over time a trusting relationship can grow.
2) Usually patients suffering from psychosis have a brittle grandiosity regarding their own magically destructive potential. One false move and someone or everyone or the entire planet will be destroyed. They thus dread the excitement accompanying feelings of hope or creativity. Therapists must respect this profound dilemma and be cautious in their pleasure when patients reveal their hidden intellectual and aesthetic capabilities. They must not provide facile reassurance that they understand the extent of this dread and magnified primitive guilt.
3) Assume that patients will test the clinician’s endurance, and will manage, through heightened self-protective sensitivity, to ferret out the clinician’s own personal vulnerabilities and defensive styles. Patients will confront the therapist’s resolve by making him or her defensive, suffering his or her own version of defeat, confusion and isolation. The greater one’s self-awareness, the more comfortable one can be in crazy situations, acknowledging one’s own crazy aspects: hence the importance of personal psychotherapy or psychoanalysis for mental health professionals.
4) Look for possibilities for playfulness and creativity. Do not stay in a hide-bound constricted office setting, protecting oneself with one's ’professional paraphernalia, but get outside and walk with the patient, both looking ahead, rather than staring each other down. Having fun together equates with working towards increasing strength and health; playfulness is not an avoidance of the work. Patients suffering a schizophrenic breakdown in adolescence usually have not mastered the latency aged task of chumship (Sullivan, 1953).
5) Do not leave all the work of talking to the patient; leave “let’s see what comes to mind” for those who choose the analytic couch. Instead, feel free to bring in your own associations, and to help the patient organize the topics under discussion. Engage in dynamically informed conversations, rather than waiting for the right time to make an interpretation (Silver, 1989, 1993, 1997.).
6) Summarize each session—the topics discussed, the conclusions reached, the plans made.
7) Encourage your patients to let you know when you have erred, and how so.
8) Abide by ethical rules of conduct. There must never be physical or sexual abuse or provocation. And just as one should never make physical demands on a patient, one should not push him or her to discuss topics mainly of interest to the therapist.
9) Meanwhile, the therapist should give the patient an opportunity to discuss past traumas: “Has anyone done things to you without your permission?” is too seldom asked, especially given the very high incidence of childhood sexual abuse in the past histories of patients suffering from psychosis (Read, 1997, 1999).
10) Treat the patient in the manner you would want to be treated. No matter how dilapidated or preoccupied the patient may seem, he or she has an acutely functioning ego, assessing the other person’s reliability and trustworthiness. Ultimately, if the therapist works at imagining what life is like for the other person, this is less tiring than keeping one’s own defensive distance. Meeting the patient’s alienation with one’s own leads to exhaustion in both parties in the defeated dyad.
Theoretical debate may seem an idle distraction. After over a decade of managed care’s assaults on inpatient and community program reimbursements, people suffering from schizophrenia are failing to stay connected with the places designated to provide care. They populate our jails, are too often homeless or living in subsistence dwellings. They zip through the revolving doors of inpatient settings that are authorized to perform only cursory evaluations within ridiculously short authorized stays. ...
The shorter the hospital stay, the more aggressive the pharmacologic regimen has become. Patients now are prescribed mind-numbingly complex regimens that their prescribers would have trouble keeping straight. I doubt that these psychiatrists would risk ingesting such regimens themselves for a single day. We know little about the primary effects of these medications given individually let alone in combinations. Probably we know nothing about secondary and tertiary effects. How many mental health professionals know, for example, that olanzapine, the rather new and popular anti-psychotic agent additionally prescribed to borderline and very anxious neurotic patients, is a thienobenzodiazepine, that is, a sulfurated benzodiazepine? But most importantly, if one reviews the mechanisms of action of the various psychiatric medications, one finds a listing of the neuro-transmitters affected. However, the primary effects are complex, and the secondary and tertiary effects are essentially unknown.
The pharmaceutical houses, in their information presented in the Physicians’ Desk Reference essentially all admit that the drugs’ mechanisms of action remain unknown. When these are combined with anti-anxiety, anti-seizure, and anti-depressive agents, we are combining agents whose mechanisms of action are even less well defined, ultimately described simply as “tranquilizing.” Psychotic patients often ingest seven different compounds daily.
What does it mean when we rather blindly tinker with our patients’ brain wiring, while evincing no interest in what they are thinking or feeling? When we chronically block a neurotransmitter, does the receiving nerve atrophy like a muscle cell held inactive too long in a cast? What does this do to the clinician’s humanity and dignity? What is the countertransferential consequence of such reductionistic practice? I worry about the possibility that there is a secret epidemic of self-medication by psychiatrists. As I hear of cases of tardive dyskinesia in patients chronically receiving SSRI’s, I suspect that the tongue thrusting I see in some of my colleagues may signal their self-medicated chronic professional despair. Psychiatrists are often tasked in clinics to work productively, seeing three or even four patients each hour, to monitor their medications, meeting with them every month or so.
Recently I was told of a clinic director who recommended “meds checks” on a twice yearly basis, reprimanding the junior clinician for “over-scheduling” appointments on a monthly basis, thus demonstrating problems with “limit-setting.” A social worker in such a clinic quoted the psychiatrist who asked, “Why are you talking with this man? I’m giving him medications.” This doctor seemed to say that the patient is not worth talking to, is somehow pre-verbal or perhaps sub-human. And this in Harry Stack Sullivan’s city, where we often quote his aphorism, “We are all more simply human than otherwise.” This is the city of Frieda Fromm-Reichmann, whose newly released biography by Gail Hornstein is aptly titled To Redeem One Person Is to Redeem the World.
I find these developments horrifying. Why at this time would psychologists want prescribing responsibilities? How do my colleagues do it, day after day, directing befuddled patients to ingest powerful concoctions that are mysterious individually and in combination even for the person writing the scripts? What about the Hippocratic Oath, to do no harm? And how has it come about that psychodynamic therapy is deemed “too dangerous” for those who have endured a psychotic storm? Where are the supporting data?
Intriguingly, the Hippocratic Oath begins “I will look upon him who shall have taught me this Art even as one of my parents. I will share my substance with him, and I will supply his necessities, if he be in need”. We have a responsibility not only to our patients but to our mentors as well, in this current era of quick, technical, impersonal solutions to society’s or individuals’ problems. Searles, who was my analyst until he dared to retire and move away, wrote in 1975 railing against the already strong reliance on pharmacologic agents. “[Patients with schizophrenia] have written off their fellow human beings as not kin to them, [and]… their fellow human beings have come to accept this as functionally true. If the psychoanalytic movement itself takes refuge in what I regard essentially as a phenothiazine-and-genetics flight from this problem, then the long dark night of the soul will have been ushered in, not only for these vast numbers of schizophrenic patient…but also for those relatively few psychoanalysts who are particularly interested in this field”.
Happily, we are beginning to hear of research demonstrating increasing cerebral synaptic development in psychotherapy patients of whatever diagnostic category. As such reports acquire greater validation, there will be renewed interest in the art and science of psychotherapy. Seeing, currently, is believing. Pinking up of frontal lobes over the course of effective therapy will be deemed more objective proof than the case write-up of the participant-observer (and thus biased and not monetarily disinterested) treating clinician. Additionally, Scandinavian studies by Tienari (1992), Alanen (1997 a&b), and their colleagues have shown that early psychological intervention in families where a young child has been identified as socially dysfunctional correlates with a national decreased incidence of schizophrenia as that population enters teenage and early adulthood.
One might presume, then, that a pro-active quest for such psychologically vulnerable children might provide convincing data to support intensive family and individual therapy for children and their families who are failing to meet socio-developmental landmarks. This probably will not happen. Just as we are seeing an escalation of prescription of methylphenidate (Ritalin) and fluoxetine (Prozac) in two and three year olds who act up at their day care programs, we may soon see young children who have never been psychotic placed on anti-psychotic medications to spare them the possibility of breakdown. The newly formed International Association of Early Psychosis, headed by Thomas McGlashan and Patrick McGorry, hopes to seek out such children in the United States and elsewhere. They will compare outcomes for a control group, a group receiving prophylactic antipsychotic medication such as olanzapine, and another group receiving cognitive behavioral therapy. McGorry told me there will be no group receiving psychodynamic therapy, which he feels is “too dangerous.”
Studying the history of psychodynamic applications to the treatment of schizophrenia, I find that this work has been a political “hot potato” from the earliest years of psychoanalysis in the U.S. (Silver, in press) I have found a cluster of papers in the Bulletin of the New York State Hospitals, beginning in 1908, by Adolf Meyer and his associates. These pre-date Freud’s famous Clark University lectures given in May of 1909. The psychoanalytic establishment’s strong reaction to Rank and Ferenczi’s 1924 “The Development of Psychoanalysis” starkly illustrates the division between an intellectually interpretive approach to “analyzable” patients on the one hand, and an “erlebnis” or experientially based approach on the other.
Tensions were vastly compounded by the World Wars, especially by the psychosis of the Holocaust. The forced immigration of many analysts to the United States became a complex cultural invasion. Our professional organizations perhaps enacted aspects of the world war. For example, Frieda Fromm-Reichmann was asked at a meeting of the American, “What right do you have to call yourself a psychoanalyst?” Elitism greatly impeded communication within the mental health field and has alienated family members as well. Now, however, as was clear at the recent meeting of the International Association on the History of Psychoanalysis, so-called mainstream psychoanalysis is significantly more interpersonal, or “intersubjective” than in earlier decades, and more receptive to the treatment of patients suffering from psychotic illness. Simultaneously, cognitive behavioral approaches are becoming more individualized and long-term.
The International Society for the Psychological treatments of the Schizophrenias and other psychoses, ISPS, and its United States Chapter aim 1) to provide information and collegial support for those mental health professionals working with patients suffering from psychotic illnesses and 2) to bring issues regarding patient care to the attention of the general mental health community and the public and 3) to work for the improved understanding and care of those suffering from psychosis. I.S.P.S. began in 1956. ...
As Gaetano Benedetti and Maurizio Peciccia have said (unpublished) “Biological research into …schizophrenia has…, over the last twenty years, become more and more fascinating; but psychodynamic reflection on psychopathology remains indispensable because only this forms the obligatory connection between the brain disturbance and the human condition of the patient.” If we lose a humanistic striving to understand each human being who comes to us for psychological assistance, we forego the essence of professional availability. If we objectify those who are most alienated from society, we relinquish our responsibility to build an I-Thou relationship, and encourage in its place an I-it, dehumanizing one. While we may want to learn about the latest “scientific progress” we must guard against the dangers of scientific regression, in which participant observation devolves into objectification.
Source: Psychoanalysis and Psychosis: Trends and Developments
See also: ISPS: International Society for the Psychological Treatments of Schizophrenia and Other Psychoses