Schizophrenia is a major cause of disability worldwide with a roughly stable prevalence of approximately 1%. The outcome in Western society has generally been viewed as being poor with a tendency to regular relapse or chronicity in the majority. There would appear to be no convincing evidence as yet of any explanatory underlying disease process. It would seem most likely that schizophrenia represents the syndromal manifestation of a variety of diverse accumulated insults to psychological functioning. These would include combinations of the following stressors: genetic, biological, environmental, and psychological. The different combinations of these elements in each individual formulation will contribute to the form and content of the actual psychotic symptoms displayed. This chapter will attempt to outline how the different main psychological treatment modalities (psychodynamic, cognitive-behavioral, and family) conceptualize and work with these diverse presentations of positive, negative, and linked affective symptoms. Process of therapy along with models of therapy effect will be described. Possible pitfalls will be outlined with strategies to overcome these. The evidence base supportive of each intervention will be stated. The chapter will end with a discussion of future research and training directions in relation to implementation.
Psychological interventions for schizophrenia probably began with exorcisms in primitive societies where possession by an evil spirit was deemed to be the cause of the problems. This concept has not gone away and even today some patients and carers seeing a frightening and inexplicable change in their psychotic relative, will request exorcism. This can lead to problems in the therapeutic alliance and in such cases therapists of all modalities would need to explore the patient's models of illness and treatment before deciding on how to proceed. Following the years of magical treatments and simple incarceration (which would again appear to be on the increase) moral management of schizophrenia began with the founding of the Retreat at York in the UK by William Tuke in 1792. Moral treatment included respect for the patient, pleasant grounds for recreation, and adequate facilities for sheltered occupation (Tuke, 1889). Psychological models of psychosis really began with Freud. In his early investigations into paranoia, he theorized that paranoia was a ‘neurosis of defense’ and that the chief defense mechanism was projection (Freud, 1895). Later he analyzed the persecutory delusions of Schreber from the latter's memoirs (Freud, 1911). In this analysis, as well as extending the theory of paranoia, Freud investigates the inter-relationships of narcissism and the vicissitudes of the sexual drives and gender identity in psychosis especially in the face of frustrations and disappointments. Harry Stack Sullivan, influenced by object relations theory, extended this model and ended up by concluding that schizophrenia was a functional psychological disorder in which symptomatic improvement could be expected with psychotherapy (Sullivan, 1962). Fromm-Reichman (1950) stressed that patients with schizophrenia exhibited a degree of motivation for engagement in therapy despite a pervasive distrust of others due to adverse early life events. Meyer (1950) echoed this therapeutic optimism in his biopsychosocial model of mental illness and his acceptance of a need for an autobiographical anamnesis or history to clarify symptom onset and dysfunctional adaptive styles. Until the development of psychoeducational family work, which evolved less than 30 years ago, very little research had been published on the use of family interventions within the field of schizophrenia. The view of the role of the family in inducing, developing, and sustaining schizophrenia changed over the years. This was related to changes in illness models from biological to personal weakness to posttraumatic. Researchers such as Bateson et al. (1956), Fromm-Reichmann (1950), and Lidz et al. (1957) stated that the parents of patients with schizophrenia were cold, dominant, conflict inducing, weak, or giving double communications. Statements such as this were not inclined to develop a good carer perspective on the possible benefits of family therapy. This situation was worsened by the dearth of any valid research evidence. In the late 1960s the English psychiatrists George Brown and John Birley (Brown and Birley, 1968) asked the crucial question ‘Why is it that some persons with schizophrenia manage to cope well after the initial episode of psychosis while others do not?’ They believed that extraneous factors influenced the subsequent course and therefore wanted to investigate environmental factors. They discovered that a family milieu with excessive criticism, hostility, overinvolvement, and lack of warmth toward the patient contributed to an increased risk of relapse (high expressed emotion family, high EE). Variables found to reduce relapse were warmth, acceptance and positive comments towards the patient (low expressed emotion family, low EE). Falloon et al. (1985) and Leff and Vaughan (1985) stressed in their ground breaking work just how crucial the family environment was in relation to the issue of relapse in schizophrenia.
Although a cognitive approach was being used in the nineteenth century by such renowned psychiatrists as Esquirol (1938), it did not achieve prominence again until Beck in 1952 described a seminal case. In this paper he described the use of a psychodynamic formulation with cognitive and behavioral techniques to achieve symptomatic improvement and eventual remission in a patient with a systematized persecutory delusion. Treatment manuals later followed (Kingdon and Turkington, 1994; Fowler et al., 1995). Integrative cognitive models of symptom emergence and maintenance were only developed much more recently (Garety et al., 2001). The new millenium has seen the further development of interpersonal therapy, cognitive remediation, and cognitive analytical therapy in the treatment of schizophrenia. As psychodynamic therapy was the first approach to be developed followed by family therapy and then, more recently, cognitive-behavioral therapy (CBT) this order will be followed in describing techniques throughout this chapter.
Descriptively, all psychodynamic models of psychosis would concur with most other models of psychosis that various aspects of ‘normal’ synthetic mental functioning have become disturbed. In keeping with the usual meaning of psychosis, it is various aspects of ‘reality’ that the mind cannot synthesize or integrate.
Where psychodynamic models diverge significantly from many other models is the centrality of the theory that psychotic phenomena are the result of a balance of dynamic mental forces that have purposes and functions for the individual. These may include unconscious motivation, meaningfulness, and meaningfulness avoided for defensive reasons. Psychodynamic models are often compatible with aspects of other models, providing no model intends to be reductionistic (Robbins, 1993). For example, there is no need in the psychodynamic model to rule out the likelihood that variations in the genetic or other biological substrates of the brain or early environmental and neurodevelopment factors can contribute to differences between individuals in their capacity to handle cognitive or emotional loads (Grotstein, 1995).
Information reaches the mind from many sources, for example, the eyes, ears, and skin. Thoughts and memories are themselves sources of data for the mind to process. If the mind is in a state where it is ‘threatened’ by that information or has already been overwhelmed, ‘psychotic’ dynamic mechanisms may be utilized in an attempt (unconscious motivation) to rid one of that information with its unacceptable meaning or further overwhelming affect. The consequences of these processes result in the symptoms and signs of psychosis.
In psychosis it is common for the sensory and mental apparatus (that are usually sources of information) to be used by the psychotic aspects of mind as routes by which information about reality, including the ‘reality’ of unacceptable internal thoughts and feelings can seem to be eliminated from awareness. Hence the vast range of areas of potential disturbance, e.g., auditory hallucinations, tactile phenomena, and disorders of thought and ideation often attributed to other minds (resulting in persecutory psychotic phenomena).
Many psychodynamic and other practitioners now recognize that persons with psychosis have both intact aspects of their minds or personalities and other aspects that have been taken over by the psychotic process. Bion (1957) described these very well in his paper ‘Differentiation of the psychotic from the non-psychotic personalities’. The nonpsychotic aspects of the personality are able to take in and integrate reality, such as information provided by the sensory and thinking apparatus. By contrast psychotic aspects of the person, unwilling or unable to tolerate mental pain or frustration, ‘attack’ those aspects of either the mind itself or the perceptual sources of these unwelcome realities (Bion, 1959). Both may coexist in complex relation with one another as in the following vignette:
A 66-year-old widow Y, with diminishing resources of all kinds, was increasingly overwhelmed by the belief that she was being subjected to attempts to steal all her possessions by persons who tried to enter her flat through gas pipes and cracks in the floorboards. This lady went to the mental hospital to complain rather than the police station. [This case also illustrates the attempt to project (externalize) the source of her diminishing resources, as she found it too painful to be aware of her own increasing frailty including her aging body.]
So in psychodynamic models, the psychotic manifestations are part of an active process that is in a dynamic relationship with the nonpsychotic aspects of the person often competing for supremacy.
A core mechanism in the psychodynamics of psychosis is the active breaking of the links between elements of information or thoughts and (in fantasy) and expelling the resulting fragments in a desperate attempt at safety (fragmentation or splitting and projection). This results in ‘bizarre experiences’. A simplified example of hallucinatory voices may assist:
A woman went on holiday without her partner and had sexual relations with others. Although she made no connection herself to the aforementioned facts, on her return she broke down into a psychosis with prominent persecutory and denigratory auditory hallucinations calling her a ‘slut’.
This could be understood as a relatively unsuccessful dynamic attempt by psychotic processes to eliminate the unbearable ‘reality’ of her own harsh internal thoughts (voice) about her behavior (her conscience). Psychoanalysts use the term ‘psychotic mechanisms’ when they are referring to psychological defenses that attempt to bypass—or even eliminate reality. They are akin to certain dream processes such as those in which the reality of time and space can be disregarded (for example, in a dream one can be in opposite sides of the world at the same time, or be several persons all in one). These contrast with ‘neurotic’ mechanisms when painful reality is retained. In this example the woman was unconsciously ridding herself of her thoughts that she might have been uncaring and self-centered in her behavior. Here the elimination/projection uses a fantasy of eliminating of internal issues via the auditory sensory apparatus so they appear to come from the external world. By a process of unconscious identification, the thoughts ‘projected’ into the minds of others are unbearable to those of others too. So the others (the voice persons) are in turn maliciously trying to force the ideas back into her. In psychosis these are experienced as concrete factual experiences and not thoughts or ideas. In neurosis, the person might present with perhaps anxiety or depression, obsessional behaviors or compulsive thoughts or punitive guilt—the common feature is that knowledge (thought) of the behavior is not being eliminated from the mind but being reacted to with other mechanisms of dealing with a painful awareness.
The example may also assist in understanding the psychodynamic model for the impoverishment/blunting of affect (negative symptoms) that is often seen in more chronic psychoses. The person mentioned above was unconsciously desperately trying not to experience affects such as loss of self-esteem or the damage to the relationship with her partner, let alone guilt, concern, and remorse. The person is therefore very restricted in the sort of life that can be led because of this much reduced (fluctuating) capacity to manage affects and reflection. This is often referred to as ego depletion or ego impoverishment. As a result of evacuation/ejection of substantial aspects of one's mind and the perceptual apparatus, the personality is depleted (impoverished).The ejected fragments continue as alienated or ‘bizarre’ objects experienced as having a personality—such as a television set, or camera usually trapping the person in a persecutory world, occasionally comforting (Hinshelwood, 1989).
The psychodynamic model of psychosis also has a major contribution to play in the understanding of interpersonal processes in psychosis. For example, it has been established from much replicated research that living in a household where there is ‘high EE’ in relatives is associated with a much greater risk of psychotic relapse (Leff and Vaughan, 1985). When therapy leads to the successful containment of such emotions by relatives the relapse rate is very considerably reduced. Migone (1995) has made useful attempts to bridge the empirical atheoretical concept of expressed emotion in terms of the three phases of projective identification espoused for example by Ogden (1979). In the first phase, unwanted or threatening mental contents, e.g., feelings of inadequacy or guilt or fears of criticism in relatives are projected (as a result they may criticize the patient or become excessively involved in order to compensate for these unwelcome feelings). In the second phase, the projecting relative(s) places ‘interpersonal pressure’ (through expressed emotion) so that the other (e.g., the psychotically vulnerable person) fits the projection, e.g., he or she is worthy of criticism (e.g., he is lazy). The latter cannot contain the projections and over time decompensates and/or projects back into the relatives (e.g., accuses the family or family member) arousing further feelings in a negative circular fashion that cannot again be contained in the relatives. The main emphasis of this psychoanalytic explanation of expressed emotion, is that of unbearable feelings in the family member(s) who try to eject outside of him or herself and locate in the person vulnerable to psychosis. It is vital to emphasize that psychoanalysts are referring to unconscious processes, otherwise these concepts will be misused and families will be blamed.
Unfortunately, these ideas, which are based on careful observations, are themselves vulnerable to the possibility of blaming family members by inexperienced professionals rather than understanding. It is important to be clear that it is unconscious mechanisms and unacceptable feelings or thoughts that are being inferred in the psychodynamic model. These cannot necessarily be immediately accepted into consciousness even through empathic interpretation.
Psychodynamic theorists continue to consider that vulnerability to psychosis is strongly correlated to prior mental development (Holmes, 2001). There is now compelling research evidence for the importance of a combination of both genetic and formative family environmental factors and their interaction in altering vulnerability to psychosis favorably and unfavorably. The evidence stems especially from the work of Tienari et al. (1994) in a long-term project that evaluated both genetic and adoptive family mental health functioning. A large number of adopted away children from mothers with schizophrenia and a control group of adopted children with biological mothers without psychosis were studied. Alanen (1997) gives a thorough review and synthesis of the psychodynamic theories on the ‘origin’ of schizophrenia. The developmental view does not exclude the clinical observations that occasionally psychotic breakdowns can occur in persons with previously well functioning personalities in the face of massive stresses (see CBT conceptualization).
The theoretical model that underpins the use of psychoeducational family therapy in schizophrenia is the vulnerability/stress model. This model explains the onset of the disease, its course, and social manifestations as being due to complex interactions between biological, environmental, and behavioral factors. The psychoeducational therapist or family group leader does not stress or address this model in treatment. The model is acknowledged as being a theoretical model and is handled with openness and a pragmatic attitude in therapy. According to the vulnerability/stress model the symptoms of schizophrenia are the consequence of psychobiological vulnerability combined with environmental stress. This psychobiological vulnerability makes the patient less able to handle the type of stress of normal adolescence. This helps families not to feel at fault for the development of the psychosis. It also takes care of the fact that for many patients developing schizophrenia it is not possible to find stressors or traumas that can explicitly explain why this person became psychotic. This also explains why some but not all children in the same family climate developed the illness, i.e., the children had different degrees of vulnerability to develop psychosis. The model also takes care of the fact that in certain families schizophrenia is very common due to genetic factors. The development of schizophrenia can take years from the first early signs to the emergence of clearly recognizable psychotic symptoms. It is considered that the onset of the illness occurs when the patient's stress tolerance has been exceeded. It may therefore be theoretically possible to prevent or at least delay the emergence of psychotic symptoms through education and stress management for patients who are recognized to be vulnerable or who are in the early stages of a psychotic prodrome. Research in this area would suggest that the delayed emergence of psychotic symptoms can be achieved in this way (Birchwood et al., 1997; Johannessen et al., 2001; McGorry et al., 2002). Psychoeducational family therapy is proven to reduce relapse following a first episode of schizophrenia when the patient lives with a high EE family. It is not yet known whether these high EE families have been so before the development of the psychosis or whether having a psychotic family member creates stress in the family that produces the typical interactional styles of the high EE family. Some current research is pointing more towards the latter explanation (Johannessen et al., 2001).
The process of CBT with the schizophrenic patient is linked to a conceptualization of the illness that is influenced by Bleuler (1911), Freud (1911), and Zubin and Spring (1977). Bleuler stressed that the schizophrenias were a group of psychotic disorders with a variety of presentations and differential outcomes. Freud stressed that psychotic symptoms had meaning and the vulnerability stress hypothesis of Zubin and Spring indicated how genetic, obstetric, infectious, personality, and other vulnerabilities interacted with stressors to initiate the emergence of the psychotic prodrome. More recently cognitive therapists (Kingdon and Turkington, 1998) have viewed the schizophrenias as consisting of five overlapping subgroups on the basis of a comprehensive review of their clinical casework.
Sensitivity disorder (which approximates to Carpenter et al., 1988, deficit syndrome) or Crow's (1980) Type II schizophrenia. This subgroup of the schizophrenias is usually described as being genetically weighted and with a gradual slide into a psychotic prodrome in adolescence. There usually appears to be minimal amounts of stress that trigger this and the presenting clinical appearance is of core negative symptoms such as alogia and affective blunting. The delusions and hallucinations linked to affective blunting are regarded as being held with less emotional investment and conviction than when affective blunting is not present (Kirkpatrick et al., 1996). These hallucinations and delusions are often highly responsive to basic CBT interventions such as reality testing and the use of coping strategies once the patient has engaged. These Type I delusions are present in the order of 50% of cases of schizophrenia.
In comparison with the above presentation the Type II delusion is less frequent. The Type II delusion is protective of underlying painful affect, such as depression, shame, or guilt. The Type II delusion usually arises after a period of intense and incremental anxiety often in middle life and is typical of a different subgroup of the schizophrenias, the anxiety psychosis. In this type of schizophrenia the Type II delusion usually presents as a systematized persecutory or grandiose delusion in the absence of negative symptoms. Sensitivity disorder and anxiety psychosis both tend to be responsive to CBT. The anxiety psychosis, however, often requires a longer intervention and peripheral questioning and reality testing alone are rarely effective. Clarification of the meaning of the delusion in the case formulation linked to work on the related underlying ‘hot’ schema seems to be necessary. Such patients will often show a degree of depression, guilt, or shame as the delusion begins to recede and the underlying hot schema is exposed (Turkington and Siddle, 1998). Whereas a good symptomatic improvement can be achieved with sensitivity disorder by a trained Community Psychiatric Nurse within a relatively brief intervention the anxiety psychosis will require 20–40 sessions with an experienced cognitive therapist if a substantial and durable benefit is to be achieved.
The third subgroup of the schizophrenias would appear to be traumatic psychosis. This is a group in which trauma is involved in the etiology of the psychotic disorder and flavors the psychotic symptoms. Often these patients have suffered from sexual assault early in life and borderline traits can be present in the personality. It would appear that any form of trauma can, however, precipitate a traumatic psychosis under certain circumstances and in relation to certain vulnerabilities. It has been reported that two-thirds of female chronic hallucinators with schizophrenia have suffered from childhood sexual assault (Heins et al., 1990). The hallmark of the traumatic subgroup is the presence of derogatory and command hallucinations. Linked schemas are often those of ‘badness’, ‘worthlessness’, or ‘being evil’. Patients holding such core maladaptive beliefs about their own value often tend to believe these derogatory hallucinations, which are trauma synchronic and they develop varying levels of depression. The cognitive therapy conceptualizations of these cases rely on cognitive models of trauma (Ehlers and Clarke, 2000) and of hallucinations (Morrison, 1998). Progress and therapy depends on the development of a clear formulation followed by the reliving of the trauma while using coping strategies to deal with stressful psychotic symptoms. Work with linked schemas allows improvement in self-esteem and self-efficacy leading to improved engagement with therapy. Such patients are often revolving door patients who seem to derive less benefit from antipsychotic medication than do sensitivity disorder and anxiety psychosis. Owing to the coexisting variable levels of depression, self harm and eventual suicide is not uncommonly the outcome unless psychotherapy is made available.
Perhaps the most difficult subgroup to work with is that with coexisting ongoing hallucinogen dependence. This group, which we have labeled drug-induced psychosis often, tend to have linked dysfunctional personality traits if not personality disorder. Those who are antisocial and rebelling against family and society in general often use hallucinogens such as strong cannabis, amphetamine, and LSD to perpetuate psychotic symptoms. This often leads to high EE in family members and poor adherence to all forms of treatment. These factors tend to act as maintaining factors for maintenance of psychotic symptoms. There is some evidence that CBT can be of benefit to this subgroup but it would appear to need to be linked to motivational interviewing in the early stages (Barrowclough et al., 2001). Coexisting family therapy to work with the maintaining factor of high EE would seem to be indicated.
The last subgroup within this conceptualization is now relatively rare in the UK. Catatonia of schizophrenic origin is now only rarely seen outside institutional settings, usually in liaison settings as a result of infectious or inflammatory origin. These patients are now usually seen on neurology wards, the bulk of the remainder of catatonic presentations, which are linked to functional psychosis, are now usually affective. Schizophrenic catatonia would appear to be the most organically weighted (Wilcox and Nasrallah, 1987) of these subgroups and, although research is sparse in this area, would seem to have least to gain from CBT and other psychological interventions.
Schizophrenia is therefore best conceptualized in relation to its psychological treatment by CBT on the basis of the above five subgroups. All of these have there own unique and overlapping mechanisms of symptom production and maintenance. Individual CBT would appear to be strongly effective in sensitivity disorder, anxiety psychosis and traumatic psychosis. It is a more difficult task but still likely to be a crucial intervention within drug related psychosis.
The first study comparing psychoanalytic psychotherapy with medication in psychosis was in Pennsylvania (Bookhammer et al., 1966) and was with young, first admission patients with psychotic illness. Tentative conclusions were that the particular form of intensive psychotherapy was about equal in effectiveness with medication. However, the research therapy was carried out in the presence of an audience, which may well have had intimidating elements (Karon, 1989).
The Wisconsin study (Rogers et al., 1967) was mainly a client-centered approach with patients seen twice a week for up to 2.5 years compared with two control groups treated with medication. Although many findings were not impressive, after termination the psychotherapy patients had nearly a 100% reduction in bed usage in the following year from 117 versus 219 days (but significant only to P = 0.1). The study was probably underpowered to test the hypothesis that length of stay was altered by the treatment. Findings related increasing warmth, empathy, and genuineness in the therapeutic relationship with other positive outcomes.
The California project, is most often quoted as showing definitively that medication is the indispensable treatment of choice and that psychoanalytic psychotherapy is ineffective (May, 1968). The same inexperienced psychiatrists treated a total of 228 different patients by five different methods (psychotherapy without medication, psychotherapy with medication, medication alone, ECT, and milieu therapy). Although some aspects of research design were impressive, a major limitation was the absence of any quality control measures of the therapy and therapists. In addition, the ending of therapy and the final evaluations both took place on the very day of discharge from hospital! This is hardly a neutral time for a patient with schizophrenia patient in psychotherapy. It could be said that this study showed that psychotherapy of schizophrenic patients by inexperienced therapists in a hospital setting is not beneficial, but few other conclusions could safely be drawn.
In the Massachusetts study (Grinspoon, 1972) Karon (1989) highlights again the poor quality control of the therapists who were not experienced with either chronic schizophrenic patients nor with the economic and ethnic culture of the patients they were treating. More than half the patients had received ECT or insulin comas and all had been in a state hospital for more than 3 years. Behavioral measures did not improve for the psychotherapy patients but 68% were able to live outside hospital compared with 37% of the (nonrandomized) control group.
The trial of treatment of schizophrenia in which quality control of the psychotherapy itself was most carefully protected is that by Karon and Vandenbos (1981) in Michigan. Although numbers were small (36), the patients tended to be severe cases from seriously socially disadvantaged backgrounds. The main problem with this study is that the control group patients were moved from the admitting hospital, if they did not improve sufficiently for discharge, to a state hospital albeit with better auxiliary facilities than the admitting hospital. This was in contrast to the two groups involved in psychotherapy that remained in the admitting hospital in order to be able to receive the psychotherapy. With this important proviso, blind evaluations at 6 months showed that the results of the inexperienced therapists could be accounted for solely by medication effects as in the California study above (May, 1968). However, at this stage the quality controlled experienced psychotherapists had significantly better results in terms of reduction in hospitalized days and measures of thought disorder, whether or not medication was administered. By 12 months the patients of the inexperienced but supervised therapists were functioning better than the control group on medication. At the end of 20 months, psychotherapy (average 70 sessions) was more effective than medication, with the patients of the experienced therapists showing a balanced improvement across all measures.
Two years after termination, psychotherapy patients had half the number of hospitalization days compared with the medication control group and patients of experienced therapists did better than those of the inexperienced. Changes in thought disorder seem to be a better predictor of longer-term ability to function outside hospital than short-term behavioral criteria, supporting other researchers’ findings.
There is a consistency in all the studies quoted above that psychotherapy patients spend less time in hospital than those in medication alone group controls. The Michigan study had a number of cost evaluations that were positive in the long term for the psychotherapy group. In addition, only 33% of the latter needed welfare payments compared with 75% of those of the medication-only controls. Karon (1989) stresses that the cost benefit–findings would have been completely opposite if the evaluations were only done at 6 months of treatment.
One important point is the question of therapeutic alliance. In a psychotherapy research project that is often quoted as unfavorable to psychotherapy (Gunderson et al., 1984), the drop-out rate was very large (69%). A good measure is needed to evaluate whether the patient is generally and genuinely co-operating in the therapy (in the same way that a trial of medication would need to have some accurate means of knowing that the patient was taking it).
Overall the results of the early research into brief periods of psychoanalytic psychotherapy for persons with psychosis was not very encouraging. Further, more detailed reviews have been conducted by the following authors (Karon, 1989; Mueser and Berenbaum, 1990; Martindale et al., 2000).
It is disappointing that there has not been much recent research into treatments that offer a predominantly psychoanalytic treatment that takes account of the deficiencies in the pioneering trials just mentioned. What is clearly needed is research that aims to discover more effective ways of achieving a therapeutic alliance in the psychoanalytic psychotherapy of psychosis, that has much better quality controls of the therapists, that is of sufficient duration to study the longer-term goals associated with the goals of psychoanalytic psychotherapy. In addition there have been substantial developments in psychoanalytic theory and technique in recent decades that are likely to have given many therapists more effective clinical methods of working with the psychotic persons. For a detailed case example that also discusses a considerable amount of contemporary theory see Pestalozzi (2003).
The psychoanalytic method with patients in psychotic states has to be very different from the psychoanalytic method with patients who are in more integrated states. Certainly, techniques that may provoke further regression are not indicated and the therapy needs a good deal of structure and the active establishment of sufficient interpersonal ‘relatedness’ with sufficient trust and mutual respect. This approach represents a considerable change from the practice during the time when much of the older research in psychoanalytic psychotherapy with psychosis was conducted. This older research had a number of limitations that have been extensively commented on from different perspectives.
In contemporary times, psychoanalytic understanding and psychoanalytic psychotherapy is most widely incorporated into the need-adapted approach that is practiced widely in Scandinavia (Alanen et al., 1991). Here a range of interventions are used according to a comprehensive ongoing evaluation, including a psychodynamic understanding of each patient's specific situation. The full range of approaches are based on the establishment of a secure therapeutic relationship, which may move into more formal psychoanalytic therapy.
Two persons with similar forms of hallucinations and delusions will vary enormously in their motivation and in the life situation in which they have developed a psychosis. Need-adapted treatment decisions will center on these individual differences and contexts. Randomized controlled trial research would tend towards focusing on a particular treatment and evaluating outcome of the symptoms that were common to a group of patients. The randomized controlled trial design, by its nature, draws inferences from groups the membership of which is determined by randomization between two (or more) alternatives that can be described as in ‘equipoise’ (i.e., there is a plausible case for either option being superior). By contrast, the ‘need-adapted approach’ is based on a competing principle that informed choice is based on the idea that an idiographic assessment of need for each individual and the type of treatment is paramount. This could well mean that in two patients with similar psychotic symptoms, assessment might lead to a decision to recommend on other clinical grounds, a focus on medication in one, a family intervention in another and individual psychoanalytic therapy in other control trials of need-adapted approaches are therefore difficult to design. An additional problem is that need-adapted approaches are integrated ones with the overall therapy being dependent on several interventions over time rather than a single one. For example, therapy would not only hope to reduce psychotic symptomatology but aim to reengage and accompany the patient on a number of developmental trajectories that he or she has fallen away from sometimes over a period of years preceding the psychosis or as a consequence. Evaluative research therefore needs to be conducted over a period of some years rather than months.
Recent meta-analysis confirms the efficacy of family therapy in the prevention of relapse with an NNT in terms of relapse prevention in the first year of 6.5 (Jones et al., 2000). (NNT stands for the average Number Needed to Treat in this case to prevent a single relapse.) Psychoeducational family therapy has a track record of 30 years of research. Many different programs have been offered but those proven useful have all had some common elements as described by Dixon and Lehman (1995). These are as follows:
Schizophrenia is regarded as an illness.
The family environment is not implicated in the etiology of the illness.
Support is provided and families are enlisted as therapeutic agents.
The interventions are part of a treatment package used in conjunction with routine drug treatment and outpatient clinical management.
The programs usually consist of educating about the illness itself, including course, treatment, and outcome. There are regular meetings where different problem-solving methods and communication skills are learned. Other benefits of the program include support, understanding, and containment.
All research on family intervention has taken into consideration the fact that the direct goal in the treatment program is to reduce the negative expressed emotions in the families and thereby reduce the stress for the patient. This will create a healthier milieu and prevent relapse. Brown et al. (1972) created a research instrument, the Camberwell Family Interview (CFI), a semistructured interview lasting 90 minutes, to score the intensity of the critical comments, hostility, and overinvolvement in the families. During the last 10 years several review articles have been published, including Barbato and D'Avanzo (2000) and Pitschel-Walz et al. (2001) who summarized more than 30 published studies, including almost 2000 families. Although the programs differ in length from 2 to 24 months and some of them address single families and some multifamilies, a highly significant majority show a significant effect on relapse rates.
Defining relapse can be difficult. One approach is to use symptom thresholds but this can be highly subjective and depending on interpretation. Hospitalization depends on access to hospital beds and the availability of crisis teams, work on unemployment figures, and so on. All this taken into consideration, the conclusion of the meta-analysis of these studies confirms an effect on relapse equal to that of medication. Pitchel-Walz et al. (2001) conclude in their article: ‘this meta analysis clearly indicates that including relatives in treatment programs is an effective way of reducing relapse rates and rehospitalization rates in patients with schizophrenia.’ ‘Psychoeducation for patients and their families should become a basic part of a comprehensive psychosocial treatment package that is offered to all patients with schizophrenia.’ The conclusion of Barbato and D'Avanzo (2000) concurs with the above.
However, there are reasons to believe that the benefits of psychoeducational therapy are effective mainly in high EE families where a substantial number of sessions are given. Also, there are only sufficient numbers to confirm the benefits in male chronic patients.
Family therapy does not claim to reduce general levels of symptomatology or achieve a reduced burden of care, but it has been shown to be cost-effective due to the large proportion of schizophrenia costs, which are consumed by repeated hospitalization (Davies and Drummond, 1994). Implementation of family therapy in the UK has been a problem in that nurses who have trained in this modality on return to their Community Mental Health Teams have often found themselves unable to delivery family therapy to schizophrenic patients. The reason for this has been due to high case loads, lack of appropriate supervision, and the need for crisis work (Leff, 2000). Reducing expressed emotion (excessive criticism or overinvolvement) using behavioral family therapy does seem to reduce relapse when high EE is present in carers who spend more than 35 hours per week of face to face contact with the schizophrenic relative (Leff and Wing, 1971). McCreadie and Robinson (1987), however, stressed that a low EE family could be an active therapeutic factor in relation to the patient's schizophrenic illness and that reduction of the carer's high EE may not be the effective therapeutic ingredient. He also noted that many families who are assessed to be of high EE at the time of acute admission, subsequently revert to low EE status, once the stress of the acute relapse of the admission was over. Irrespective of these criticisms, family therapy has been recommended in the UK National Institute for Clinical Excellence Guidelines (National Institute for Clinical Excellence, 2002) and now must be provided by Mental Health Trusts where indicated. In comparison, individual psychoeducation has an NNT for prevention of relapse in the first year of 9.5 but there is some evidence of a risk of increase in suicidal ideation (Carroll et al., 1998). It would appear that the great weight of evidence is that family therapy can reduce relapse in certain patients with schizophrenia, it therefore seems necessary to supply an individual intervention to the patient with schizophrenia to improve symptomatology to complement the effect of family therapy in relapse.
The benefits of CBT as shown by NNTs (a binary outcome measure) are confirmed by studies of effect size (a continuous measure). CBT has been shown to have a large effect size on residual psychotic symptoms in schizophrenia by the end of therapy (effect size 0.65) with more gains at short-term follow-up (effect size 0.9) (Gould et al., 2001). It would appear, however, that the literature shows a moderate effect size for other psychological modalities (supportive counseling and befriending) in overall symptoms of schizophrenia at the end of therapy. The befriending group, however, were more significantly worse off at short-term follow-up. The benefits of CBT are apparent in terms of hallucinations and delusions (Tarrier, 1998), negative symptoms, and depression (Sensky et al., 2000) as well as overall symptoms (Kuipers et al., 1997). Brief CBT has also been delivered within a randomized trial and shown to improve adherence leading to improved symptomatology at the end of therapy and at short-term follow-up (Kemp et al., 1996, 1998). As well as this significant and durable effect on all the residual symptoms of schizophrenia, brief CBT has been shown to translate into community settings (Turkington et al., 2002). In this pragmatic trial community psychiatric nurses were trained over a 10-day period in CBT of schizophrenia and delivered this both to patients (six sessions) and carers (three sessions). Overall symptoms, insight, and depression were all significantly improved by the end of this brief CBT intervention. When CBT is delivered in the community by psychiatric nurses, by the end of therapy there is a moderate effect on depression within schizophrenia (NNT = 9) and a moderate effect on insight (NNT = 10). There is a weak effect on overall symptoms (NNT = 13), but no detectable effect on positive or negative psychotic symptoms. It would seem that the strong effects achieved with 20 session expert cognitive therapy does translate into the community but with differential effects of moderate size. Cognitive remediation is a form of retraining in relation to the cognitive deficits of schizophrenia and has also been shown to be effective (Wykes et al., 2002). It would appear potentially to be an ideal supplement in relation to the benefits of CBT in patients with sensitivity disorder. If CBT can deliver symptomatic improvement and improve adherence with antipsychotic medication and if family therapy can reduce relapse, what then is the role for psychodynamic psychotherapy?
Psychodynamic approaches (see Conceptualization) are based on the psychoanalytic model of mental functioning with its principal tenets of (1) unconscious processes dominating mental life, and (2) the centrality of the outcome of earlier life experience in determining capacities to integrate affects and also determining attitudes to key persons in contemporary relationships (transference).
In recent decades, substantial shifts have occurred in technique in individual psychodynamic therapeutic work with those vulnerable to psychosis. These shifts stem from an increase in understanding of the particular unconscious processes occurring in psychosis—especially the powerful consequences of ‘psychotic’ projections into the minds of therapists (leading to countertransference). This has resulted in a shift from a relatively exclusive focus on insight in the patient as being the factor that leads to therapeutic change, to (1) a greater focus on better containment in the mind of the professional of the experience of the patient, and (2) a much more serious awareness of the fragility of the patient's integrative capacities in the face of the strength of the need to project. This has been reinforced by the older research that demonstrated the high dropout rate and low therapeutic alliance in traditional (insight orientated) psychoanalytic therapy with persons with psychosis (Gunderson et al., 1984). Other important research has highlighted that contrary to what was expected, supportive interventions can lead to important psychic change (Wallerstein, 1995). Further developments have occurred as a result of a) deeper understandings of what is meant by containment in the countertransference.
In a psychoanalytic sense, the word ‘containment’ refers to the process whereby the therapist detects that the patient is unconsciously attempting to recruit him into acting a role in his inner drama. Containment refers to the psychotherapeutic skill of being able to accept and emotionally and cognitively digest or ‘metabolize’ the patient's projections, in the service of understanding him. It involves withstanding and tolerating the impact of the process (in the countertransference). He may eventually understand sufficiently to help the patient work through and find better ways of managing what are usually unconscious impulses and desires that he is dealing with by projection. These wishes, emotions and impulses have never before been properly acknowledged or integrated into the patient's self.
The emphasis on containment of projections in the countertransference in psychosis work has meant that psychoanalytic ideas have far more value in all kinds of mental health settings, as the following vignette will convey.
Patient A was admitted in a seriously suicidal and very psychotic state. She did not respond to medication over many weeks. When consultation was sought, the nurses mentioned how contemptuous she was of them. This was difficult for them to bear. Exploration revealed that the patient had for many years felt contemptuous of the seeming inability of her parents to even acknowledge her difficulties and had given up on them. In the consultation it transpired that, somewhat in contrast to other patients, the staff knew little about A's difficulties and background, and that A was unconsciously assuming the staff to be useless like her view of her parents. The focus of work had up till now been almost exclusively pharmaceutical, with the danger of the staff traumatizing the patient through accusing the patient of being uncooperative rather than trying to make sense of her contempt, which would be likely to be a major feature of formal individual or family therapy offered.
Although this vignette stems from work on an inpatient ward, the understanding of these sorts of experiences could apply to any mental health setting, or therapeutic format (individual, group, family, or therapeutic milieu). Psychoanalytic observers have been much impressed by the extent to which cognitive therapists recognize the power of unconscious schema in determining relationships (Padesky, 1994) and symptoms.
Psychoanalytic practitioners will be less concerned with tackling individual symptoms, than with trying to understand the meaning of the symptoms and their relevance to the overall longer-term treatment goals as will be clear from the following patient with a delusional belief:
A 25-year-old man, B, was admitted with the dominating symptom (which did not trouble HIM!) of being in love with a famous female model from another country. He believed that she was in love with him too and demonstrated how he could always call her up when he wanted and they would TALK and make love etc. A psychodynamically informed picture emerged. The sudden onset of this psychotic delusion had relieved the man of the lonely broken hearted state he had been in for weeks.
The medical approach in this case had been to find the right medication that would remove the delusion without consideration that the delusion had a psychological function (meaning and meaning to be avoided) and therefore that their recommendations of medication would be opposed. If successful in countering the delusion, B would be likely to return to the status ante in which he was very seriously distressed. A psychoanalytic approach would be to focus on establishing long-term relationship(s) in which the patient might in time feel sufficiently secure to get some attention for his developmental insecurities (which might possibly result in the patient wanting to take some medication, which he had been resisting for psychodynamically obvious reasons). The setting for the treatment for this young man would result from an evaluation of the best combination of social/therapeutic milieu, group, family, or individual therapy if resources were available. Whichever setting or psychotherapeutic modality, analytic, cognitive, or systemic, a psychodynamic assessment of change would not be satisfied very much only with the absence of delusions, but would be assessing whether B had been able to manage the affects involved in social and more intimate relations with women without psychotic deterioration.
Applied psychoanalytic approaches with patient B would involve:
Supporting B to reengage with activities that he could manage that were less problematic in order to minimize ‘collateral’ damage from the breakdown and thus reengaging on some areas where continuing development could occur.
Working at a pace that B could manage on making conscious the difficulties that antedated the breakdown as the issues that he needed help with. This was not easy work as B had long internalized in his character what one might call prepsychotic denial of problems. This was in keeping with his long experience in his formative years of his parents’ difficulties in keeping their minds open to the fact of his vulnerability and his underlying lack of confidence and to the trauma that stemmed from their divorce with its multiple implications for him. In the countertransference it was difficult for community staff to cope with B's indifference and dismissiveness of therapeutic needs and they felt pressured into going along with a leave him alone or give up attitude when he would miss appointments and seem unconcerned. In time it was possible to engage with him gradually as to how vulnerable he indeed felt with the staff to being abandoned or forgotten when he did begin to mention worries and problems. This case illustrates well the continuity between his flagrant delusion that ‘successfully’ rescued him from his too painful state and earlier ways of denying difficulties.
A psychodynamic approach would not accept without very careful evidence that a systematized delusion could arrive out of an entirely normal personality. It is most likely that most parts of the personality appear intact to others, but on careful evaluation there are areas of the mind that cannot bear certain realities and copes with them in a psychotic way. These might well be quite hidden until an event highlights the problem.
A 45-year-old man, D, sought analytic help as part of a decision in mid-life to train as a nurse. On the surface he had maintained a reasonably stable marriage and had four children and had not had previous mental health assistance. The analysis seemed to be proceeding well but after some time the analyst gave 6 months notice that for health reasons, he was not going to continue to be available. The patient was unable to function at the end of this period and sunk into a black unremitting serious depression in which suicide seemed an option. Starting with a new therapist revealed a long-standing delusional belief that had not been consciously communicated. This was that the patient had really become an integral part and equal member of the first therapist's family. A key event in the patient's history was that when he was 7 his mother had left him for some months with his father while she went with his siblings but not him to another part of the country. This had had a radical effect on his self-esteem and left him with powerful envious feelings towards those that stayed with his mother. The delusional belief about his relationship with his therapist had protected him from these unmanageable and violent feelings of being different from the therapist's family members. His decision to work in the nursing field was partly based on a projection of fears of his own needs for care as he grew older and feared he could not rely on his family.
A further example of a delusion operating unconsciously in an otherwise fairly normal personality was a 40-year-old woman, who suffered from anxiety and panic attacks only in relation to a narrow aspect of her work with a voluntary organization for persons with mental health problems. It transpired that these symptoms were related to an omnipotent delusion that she should be able to attend to all the suffering persons that came to her attention and no one should be turned away. In other ways this person was highly effective and creative.
Psychodynamic therapy in both these cases involved a long process.
Of helping the nonpsychotic part of the persons to hold on to awareness that the psychotic part of the personality with its delusion beliefs did not in fact want to come to attention. This was because of the painful feelings of loss, frustration, and destructive envy (in the first case), and that through the delusional belief these feelings would never need to be experienced.
Whereby the psychotic parts of the patients tried to recreate their delusional beliefs with the therapists (this is called the psychotic transference).
A great deal of careful monitoring was required by the therapists that they did not unwittingly go along with unrealistic expectations. They needed to be sure that they did not also overlook or unduly prevent frustration, disappointment, and envious attacks becoming conscious within the treatment relationship so that integration of these feelings into the personality of the patients was possible with expansion of nonpsychotic capacities.
The following is an example of a psychotic transference that one would normally expect to develop in such a patient:
A 40-year-old female veterinary surgeon C was in a forensic psychiatric hospital for a number of years after she had experienced several psychotic episodes. Her index offense for this admission had been to attempt to pierce a young child in the eye with a needle. Many aspects of her personality were intact, she was sociable and involved in ward life, was competent at intellectual games and kept well informed of events in the world outside. She maintained, however, that she was only in the hospital because the doctors had been poisoning her with their injections for many years and that she was in great pain as a result of these injections.
Over the years the focus had indeed been on a pharmaceutical approach, which had clearly not been successful.
She was offered a weekly session with a psychotherapist and soon developed a psychotic transference in which she had the expectation that the function of her therapist would be to take her side to tell the medical staff of the mistake that doctors had made over many years. The therapist was also to inform the doctor in charge that C was really a brilliant person who prior to admission had invented and written a thesis on new rules for tennis that would make her famous. (It was hypothesized that the attack on the child was related to unbearable envy of the future of the child, in the face of the unbearable truth of her mental illness recurring.)
It cannot be predicted what would have happened if this woman had been given a psychologically informed approach many years ago. However, what was striking in her records is the complete absence of any sign of a member of staff having engaged with her on a long-term basis to try and process anything of her breakdown and the painful consequences of this, which was all so forcefully attributed to the staff.
Mr E was a 19-year-old who had found his first girlfriend in bed with another male friend. He quickly decompensated into a very distressing psychotic state. After receiving psychodynamic psychotherapy much of his mind and his previous functioning recovered but he kept his distance from girls. He was left with tactile somatic hallucinations in his ‘thighs’, which were especially prominent before going to sleep. The sensations felt like something alien getting inside trying to control him and were sometimes accompanied by ‘a knocking at the windows and ornaments on the mantel piece rattling’—‘just as if someone was trying to get in!’
He had been unconsciously trying to be rid of sexual thoughts and traumatic memories. The somatic hallucinations in his thighs were an expression of the failure of this evacuation. They were ‘trying to get back in’.
E mainly complained about this and hoped that the problem would be ‘taken away’ and he spent much time seeking expert advice on adjusting antipsychotic medication.
Painstaking work over many months led Mr E to be clear that he was trying to cope with his trauma by happily believing that he could get on with his life ‘without girls or any wish for an intimate sexual relationship’ (getting rid of the problem). Without apparent conscious connection, he would also tell his therapist frequently how unfulfilled and meaningless he felt his life to be and how distressed he was at seeing others progress in a blissful fashion in their personal lives.
Through slow psychodynamic work, E and his therapist were able to bring these two previously disconnected aspects of his mind in relation to one another. Against much opposition, he could see that any thoughts of a sexual relationship were painfully connected with memories of being interfered with, ‘messed about’, and let down. He was terrified of a further major psychosis (i.e., he had a double trauma). The ornaments rattling on the edge of the shelf were an unconscious desymbolized expression of repeating the breakdown—the fall—if he let back in the thoughts a sexual girlfriend that he had ‘thrown out of the window’.
Psychoeducative family therapy differs from individual therapy and from therapies based on psychodynamic understandings and methods. The theories in family work do not oppose psychodynamic or psychoanalytic views and a patient can fruitfully receive individual therapy based on a psychodynamic understanding at the same time as he joins family groups. The group leader can be analytical, systemically, or cognitive-behaviorally trained. Often it is easier for a nonanalytic therapist to conduct the sessions, but it is also possible for a psychodynamically oriented therapist to lead family groups as long as the models are not mixed.
The atmosphere in family work is of cooperation, education and practical, pragmatic problem solving. The therapist also reveals more of himself and his private life than one does in psychodynamic psychotherapy.
In the session one not only deals with practical matters, but when one deals with psychological matters one does so in a pragmatic way. If the patient talks about hallucinations, one tries to find out what situation triggers them, and what can be helpful in dealing with them. The suggestions can vary from changing medication to talk more about it with the individual therapist, and often a combination of suggestions is pursued.
The same attitude is held towards delusions, anxiety, depression, or any other psychiatric symptoms that come into the open.
People with psychosis, and especially schizophrenia can for a phase of their lives suffer from cognitive impairment, and are specially vulnerable to unclear, communication. Psychoeducative family work stresses clear communication, that one is talking for himself and not practicing mind reading. The problem-solving methods used, also are easy to follow when your mind is not optimally functioning. The therapist uses the blackboard and written messages.
This is not only respectful towards the patient and the family, but is a service appreciated on many levels.
Mr and Mrs Field came to the therapist's office for the first time. Their only son had been admitted to the acute ward 3 days before, after he had spent 3 weeks in bed unable to rise and to go to the university where he studied biology.
What Mr Field expressed as his main concern was whether their son Eric would be able to get well enough to pass his exam in 6 weeks. He had always been an excellent student and, although he had been a bit mixed up and withdrawn for the latest month, he had to his father's knowledge attended lectures and been studying diligently for the last 3 weeks.
The mother sat looking down during the father's speech, using the handkerchief often at the corner of her eyes. She looked at the therapist and asked what he thought. Was it serious? How would it be for him being at the hospital? Had they done the right thing admitting him or should they have tried having him home longer?
Here we see the father's denial of the seriousness of the illness and the mothers fear, concern and guilt. The therapist has to take care of both parents on their different levels of insight. He has to take seriously the father's concern of his son's academic career, giving him realistic hopes and giving him time to adjust to the new situation. The mother is concerned about whether they have done the right thing taking him to the hospital, and the therapist can feel her concern and pressing guilt for other subjects in her mind. He also senses that the mother sees a fuller picture of the situation than the father. At this early phase it is often more important for the therapist to receive and contain than give information. The patient in the beginning of the illness often has enough with his or her symptoms and how to survive from day to day. Perhaps he struggles with the strangeness he feels, and the anxiety that goes with it. He often is skeptical to the health systems explanations and looks for other ways to understand the symptoms. He may not describe the psychosis as an illness, but sees it as an influence from outer factors. He may be confused and losing grip on reality. In this phase the therapist tries to deal with the acute situation and the crisis. The therapist meets the patient and is interested to learn his views, concerns, and his way of seeing things. He tries to explain to him that he sees the patient is trying to explain what is happening to him and that his confusion can be a result of much inner stress and a kind of overload.
Anna's parents had followed Anna to the hospital for the seventh admission in 9 years. At the therapist's office they looked a bit lost and gray. They had not been given many opportunities to talk to therapists before and did not know what to think when they were given this appointment. Had they done something wrong? When the opening question was how they felt, tears ran into Anna's mothers eyes. Never had they been asked the question before during the 9 years of Anna's illness. This opened up a well of grief and sorrow, and when the hour had passed they were not halfway through their story. They were given new appointments knowing that dealing with their guilt, shame, and fear would improve the climate at home providing a better environment for Anna on her return. It is important for the therapist to give their guilt attention without blaming, to see their sorrow and still give hope.
Jim and his parent are joining a multifamily group for the first year. Multifamily groups allow carers and patients to meet in a supportive and nonstigmatizing manner in which improved understanding and coping can be facilitated. Jim is staying at home spending most of the days in his bed. He takes his time trying to answer his mothers questions and demands, and sometimes she has a hard time getting contact with him. He wants to listen to heavy music played loud, but the rest of the family sets limits to that. In this group meeting the mother brings this up and the group leaders in cooperation with Jim decide this is the problem to address in this group meeting. To see what the problem really is about the therapist has to get a clear understanding of it and go deeper into what makes Jim lie in bed all day. At first Jim could not give an answer. He said he was tired, had no energy and did not want to get up. There was too much noise in the house and it turned out that he often got up to eat after the others had gone to bed. Asking him why he took more to eat in the night he said that the house was quiet and that there was not so much noise and disturbing sounds. The mother commented that he was not afraid of disturbing sounds when he put his music into action. But that is to get peace from all the demands, Jim answered. The demands? Yes, from inside my head. Now it became clear that Jim suffered from auditory hallucinations, and the therapist could ask him more about that. ‘What did they say… how many voices? ‘Other sounds as well… did he know them… were they angry?
It turned out Jim had a lot of hallucinations during the day, mostly two voices arguing. They grew worse when he tried to talk to others and demanded him not to listen to his parents. He found that so painful that he tried to avoid such situations where the voices were provoked.
Now the therapist knew what Jim's real problem was and could with the help of the group try to problem solve that, without interpretation of the contents of the voices or psychologically go into what situations provoked them. Medication, walkman, fight back the voices, try to talk to the family about them, just stay in bed or move away from home, were some of the suggestions the group offered for Jim to look into. It was up to him, and his family, which one they wanted to test out prior to the next group meeting.
Tina had several flashbacks after a brutal rape. She had suffered from depression with incongruent delusions and commenting voices for years and came from a family with hereditary psychosis. She was raped on her way home from being at the cinema with friends. They had taken a couple of beers before they parted, something very unusual for Tina. The rapist was a total stranger, and had he not been observed from a flat, he would probably have managed to kill her. By the time the police came, Tina was unconscious.
Her mother whom she was living with had by that time a bad period herself and urged Tina to forget all about it as soon as she could. Tina tried. She was offered some help from the health system before the case was on trial, but refused.
After some months the flashbacks, the smell, and the noises came back to her, stronger and stronger. Voices called her whore and drunk. She could not concentrate at work nor sleep at night and had to take sick leave.
At last she agreed to receive help and was together with her parent offered to join a family group. The mother still believed that the best way do deal with it was to forget, and the father believed that Tina should pull herself together and get back to work. Otherwise she would become like her mother, sitting home smoking all day. During the group meeting when Tina's problem was dealt with it turned out the father very much liked to watch crime and action films on TV. This trigged Tina's memories and did not give her peace. The group offered the family many solutions from banning action and crime programs on TV to encouraging Tina to move out. The suggestion the family agreed upon was that the father should watch TV with earphones and turn the TV a bit away from the sofa where Tina used to sit and knit. This was a suggestion where both Tina and the father had to take and give a little and there was an acceptance from the father, which apart from the practical matter of symptomatic improvement also meant a lot symbolically for her.
Peter stayed all day in bed looking at the roof. He did not seem either happy or depressed he just lay there. He knew for certain that he was one of the best computer specialists in the world and that both the Pentagon and Israel were looking to employ him. He believed that they sometimes sent messages to the room, messages only he could understand. He had a computer but had not touched it for weeks. Last time he tried everything got mixed up and he took that as a secret sign that he communicated with the outside world in a special way.
He was the youngest in a family of famous academics, and was the only one without an academic career. His parents had always loved him the way he was, even though they did not always understand him. One could not deny that much of the discussion in the family was about the different academic careers.
In the group meeting mother complained about Peter just laying there. Peter said he did not care to get up. Both parents were sitting at their computers anyway, and when his brothers visited they only talked work. Mother admitted that this was true, and so they started problem solving that situation to see if there was anything the family could do to make it more attractive for Peter to join them, without dealing directly with Peters feeling of inferiority and sorrow that made him develop his grandiose delusions.
Luke was a perfectly normal engineer or so most people believed. He was clever at work, likeable, and good humored. He was always working at inventing new machines, and now he was trying to take out a patent on his latest invention, a machine that could create energy from earth. ‘Just dig a hole put it in and there will be no need of the electricity or oil industry anymore’. Because of his background and seemingly healthy personality he managed to get publicity about his work seeking for investors. Those who looked further into the project discovered lots of things that did not go together. Dealing with this problem psychoeducationally would address how he could get a channel for his creativity and wish for fame and money that came from his day dreams, which helped him to survive his extremely deprived childhood.
Very seldom do patients like Luke agree to treatment in a psychoeducative family setting. They usually manage so well in so many fields in their life that very seldom the whole family get engaged in a treatment program. Very often the patient himself will not attend.
Beck (1952) on the cusp of moving from his psychoanalytic practice to his description of cognitive therapy described some of the key practice principles in a seminal case of the psychological treatment of paranoid schizophrenia. In this case reality testing homework experiments were linked to the generation of a psychodynamic case formulation. This was developed following an examination of the antecedents of the psychotic breakdown. The delusion in question was linked to underlying repressed guilt at the schema level ‘I am responsible for my father's misdemeanors’ and’ I should be punished for my weakness’ and Beck's patient was helped to understand the formulation and systematically work with the delusion until it eventually receded. This is a classical description of a Type II delusion within an anxiety psychosis.
In terms of CBT the development of a trusting relationship in which collaborative empiricism can flourish is paramount. The pace should be slow to allow for cognitive deficits and ongoing symptomatology, such as hallucinations or delusional preoccupation. There should only be one target problem with one linked homework exercise per session. Patients, except those who are very paranoid, usually appreciate audiotapes of sessions in order that the session can be replayed at home. Indeed, much of the early progress from CBT sessions can arise while trust is developing within sessions through a gradual increase in understanding and gentle realty testing as described in the audiotapes. Therapists should maintain an open mind as they enter these early sessions and be prepared to disclose their own beliefs in relation to a wide variety of subjects from hypnosis and witchcraft to alien abduction and kundalini (chakra energy centers) phenomena. Often the therapist will have to say quite honestly ‘I don't know much about this’ ‘let me go and photocopy some articles which we can discuss next week’. Sessions should be variable in length depending on levels of concentration, stage of therapy, and level of symptomatology. The agenda needs to be carefully set and it is usually necessary to work with the patient's model or explanation for their symptoms before working up other possible explanations for testing. Avoidance of confrontation or collusion along with strategic withdrawal in the case of any exacerbation of symptoms are important strategies. The therapist should be honest, open, clear, and empathic and should be prepared to share their own views and opinions. Humor often helps improve the quality of the therapeutic alliance and makes sessions memorable. Both therapist and patient should be prepared to undertake homework for the next session. A key strategy is to use normalizing to decatastrophize and destigmatize schizophrenic symptoms. Often the cognition surrounding the label of schizophrenia is so anxiogenic that the primary symptoms of schizophrenia, for example hallucinations and paranoid delusions, are exacerbated. Such anxiogenic automatic thoughts might include ‘I will be a danger to others’ or ‘I am a psycho’ and ‘I will be locked up’. Normalizing stresses the fact that voice hearing is very common in the general community for example in sleep deprivation (Oswald, 1974) or in hostage situations (Keenan, 1992). Normalizing is extremely useful in not only making the patient feel less stigmatized and less alienated but can also actually improve their ability to cope with their hallucinations as they begin to take a less catastrophic view of them. Once the therapeutic alliance is established with viable joint working and the development of trust develops then examination of the antecedents of the psychotic symptoms can begin in order for the patient to develop insight into their vulnerabilities and the stressors that tipped them in to these particular psychotic symptoms. Further exploration of childhood experiences can allow a full case formulation to be developed and shared with clarification of underlying schemas.
For example,
Therapist: ‘the Christ thing’… how did this happen? how did you come to hold this belief’
Patient: I lost my job then the wife left….
Therapist: How did you feel? it sounds like a really rough time for you?
Patient: I was really low and then really nervy and upset….
Therapist: What happened next?
Patient: I was trying to read the bible to get some answers but kept getting more anxious about it all…
Therapist: What then?
Patient: I had not slept for two nights and then I started to feel kind of strange (delusional mood) and then I saw a cross of clouds in the sky and realized that my problems were linked to the fact that I was the second coming of Christ.
Explanation of this man's childhood revealed that he had always believed that he was a failure (due partly to the critical comments of his perfectionist father) and throughout life he had striven to cope with this by striving for success. The invalidation of his achievement schema due to a series of life events led to increasing anxiety, delusional mood, and the eventual crystallization of a grandiose delusion to protect against the underlying core maladaptive schema, i.e., ‘I am a failure’. Armed with the above formulation a direction of therapy becomes apparent with the possibility of the emergence of depression in due course. Once a formulation has been agreed and developed in homework sessions symptom management is then the next step. Within the deficit syndrome (sensitivity disorder) hallucinations are usually dealt with throughout the following series of steps.
Usually such patients presume that others can hear their voices and have not checked out on their geographical location. This is usually linked to avoidance of engagement with the voices and impaired coping. If the voice is active during the session this should be seen as a great opportunity and the therapist and patient can search the immediate vicinity of the consulting room to look for the source of the voice. Thereafter a list of possible explanations for the phenomenon can be constructed together. Audiotaping during the session when the voice is being heard by the patient should lead to a negative result when the tape is replayed, which can be greatly reassuring to the patient who is often embarrassed by the voices’ content. The next step would be to take a baseline recording of voice activity using a simple voice diary to detect any fluctuations of the voice hearing experience. Such a recording is usually a mater of some interest to patients and they are usually agreeable to write down the various fluctuations in the intensity of the voices. Review of the diary usually shows times of silence or greatly reduced voice intensity linked to certain affects and behaviors. Continuing to use the voice diary combined with an activity schedule can allow a coping strategy, for example, increase socialization to be tested during the following week.
Therapist: It looks like the voices are more in the background at certain times…
Patient: Yes when I was playing the computer game it was easier to ignore them… they went right down when I was playing pool in the pub with my friend… when I was bored and sitting on my own at home they were a real pest.
Therapist: Okay so lets give the voices a score out of 10 for how much of a pest they are and lets do 1 hour of the computer game each afternoon and 30 minutes of sitting being bored each day at night and lets see what happens.
Voices that are not traumatic in origin usually show some benefit from these simple techniques and lead to an increase in perceived control and self-efficacy. The affect linked to the voice hearing is often a potent reinforcer.
Therapist: When you were in the corner shop and the voice was talking about you, what were you doing and how did you feel?
Patient: I was trying not to look at anybody and I felt annoyed and embarrassed….
Therapist: What was going through your mind?
Patient: I was thinking ‘how dare they why pick on me’ and ‘its not fair what if somebody else hears that’.
Therapist: So you normally run out when this happens
Patient: Yes
Therapist: Can you remember when we tried to tape the voice? There was nothing to be heard on the tape and I know that you have asked your GP and he said that he could not hear them… is that right?
Patient: Yes no one seems to say that they can hear them.
Therapist: So maybe they are really caused and worsened by stress and if you get angry then you are more stressed. Lets try and see if we can stay in the shop a bit longer and talk ourselves through it and bring the anger down. What could you say to yourself to make yourself less angry?
Patient: I could say, ‘it is just me being stressed’ and ‘no one else can actually hear them’ and ‘I will stay in the shop and see if they start to settle down a bit’.
Usually a normalizing explanation linked to behavioral experiments in cognitive homework as described will often show clear benefit. Voices, however, can be linked to underlying schemas and then it is helpful to use rational responding linked to schema level work.
Therapist: You came to believe early on in life that you were different from other children is that right?
Patient: Yes at school I was bullied….they said I had ‘the touch’ if any of them touched me they ran away screaming and tried to touch somebody else to get rid of ‘the touch’
Therapist: When did this all start?
Patient: I was in hospital with really bad measles and my skin was marked for a number of months thereafter…
Therapist: So what do these voices say?
Patient: They say ‘she is ugly’, ‘don't go near her keep away’
Therapist: We know how cruel children can be but the voices sound like they were from that very early time of your life…
Patient: Yes the voices are children's voices…
Therapist: This is obviously a painful subject would you like to do some work on this?
Patient: Yes okay (upset)
Therapist: In terms of how different you believe yourself to be from others where would you place yourself on this scale from completely different to completely the same as others? (use of the continuum)
Patient: Points to the extreme different end of the scale and also places the Elephant Man and Pinocchio at that end of the scale.
Therapist: Why not over the next week answer the voices gently back by talking to them, for example, ‘I have left that time of my life behind’ ‘I am not so different really anymore’. Also let's write down in this log how often it actually happens in the course of a week that one of your friends or relatives says or indicates to you in some way that you are very different from others (positive log)
The techniques as described above work from superficial to deep and usually will achieve some degree of improved control and reduced distress linked to the voice hearing experience.
The voice-hearing situation is complicated further when there is an underlying trauma, which is congruent with the voice content and with linked schemas. Here there are other maintaining factors, including increased arousal and prominent avoidance of linked stimuli. There can also be abuse congruent visual imagery or even visual hallucinations linked to the voice hearing. If the patient is psychologically robust enough and agreeable to a reliving approach based on imagery linked cognitive work then the trauma can be tackled directly as in posttraumatic stress disorder. Otherwise the core trauma should be left and linked schemas worked with. Such schemas usually include ‘I deserved it’, ‘I am guilty’, ‘I am bad’, or ‘I am unclean’.
These are those in which there is a jump into delusional knowing during the psychotic prodrome often linked to cognitive deficits and negative symptoms. In sensitivity disorder there is a gradual slide into social withdrawal, magical thinking, affective blunting, alogia, and depersonalization with sleep deprivation. In such a state patients will often jump to an explanation of this bizarre change in themselves based on current media topics, which are prominent in newspaper and television reporting in relation to phenomena, which are not fully understood. Religious delusions and witchcraft used to be very common in delusional content but they are now much less so. They have been replace by microchips, satellites and aliens as the subject matter for Type I delusions. Type I delusions have much less of the typical features as described by Jaspers (1963) they are also more straightforward to treat. The patient should be engaged in an open and interested manner and a model of the delusion gently explored and tested out gradually with reality testing both within and out with the session. At times the help of a key worker or carer can be crucial to help the testing out process during the early stages. Guided discovery using Socratic questioning on the basis of the evidence produced will lead to the elucidation of other possible explanations. Confrontation and collusion need to be avoided but the therapist should try to be consistent in their opinions and express word perfect accuracy.
Patient: The republicans have my house under surveillance, there are CIA agents outside in cars…
Therapist: You seem very upset there must be a reason for this.
Patient: The CIA have bugged my phone, I am absolutely sick of it.
Therapist: You could be right… the CIA are certainly well resourced and do work undercover but how do you know it is the CIA rather than some other organization or some other explanation altogether?
Patient: I just presumed it had to be the CIA.
Therapist: Well let's do some homework on this… could you have a think of any reason why you might be under surveillance by the CIA? Also could you check three times a day to see if a car with people in it is actually parked in your street somewhere? I will check in the newspapers to see if the CIA are involved in this neighborhood just now and we can discuss it again at our next session.
Beck (1952) explained the importance of focusing the patient's reality testing on specific areas of enquiry. Examples might be as to what kind of car would they be using, what would they be wearing, what would their facial expressions be like? In relation to Type II delusions, which are rarely linked to negative symptoms, the above approaches are of much less effect and work with the underlying linked schema seems crucial. The delusion in such a case is often a systematized persecutory or grandiose delusion and is usually protective of a strongly emotionally invested underlying schema (Turkington and Siddle, 1998).
Patient: I am in charge of all NATO forces.
Therapist: What might that mean to you (interested)
Patient: I can put things right… there is so much that has gone wrong. (entitlement schema)
Therapist: Why would that be so important?
Patient: I was always the black sheep of the family, dad never gave me a fair deal (anger and distress)
Here the inference chain has led very quickly to an underlying core maladaptive schema of being the black sheep of the family and a compensatory schema of a demand for entitlement. This man's systematized grandiose delusion emerged in his mid-forties after he was dismissed from his rank as a Corporal in the US air force. He had devoted his working life to the air force and he had stood up against what he believed was unfair treatment of a colleague who had died in the course of service. He believed this was due to the negligence of his superiors and after he had attempted to prove this by writing and publishing a report saying so he gradually developed increasing anxiety and the emergence of the grandiose delusion when his claims were denied by superior officers. Here work on entitlement would allow the grandiose delusional system to start to become less prominent with the emergence of depression over the underlying core schema of being the black sheep of the family.
These need to be briefer as they are hard work for both therapist and patient. The intermingled themes can often to a degree be disentangled on review of a videotape of the CBT session. A videotape analysis also allows a review of body language at times of increased arousal in relation to certain themes. It can usually be discovered that there is one key theme that is driving the thought disorder (Turkington and Kingdon, 1991). Thereafter the sessions are organized using focus linked to explanation, education, and rapid responding to reduce the key driving affect behind the thought disorder. Thereafter, whenever the patient jumps from ‘x’ to ‘z’ as in a knight's move jump the therapist brings the patient back to clarify the link by asking him to explain the links between ‘x’ and ‘z’, i.e., to put in the ‘y’. Patients can usually do this. Work is focused thereafter on the main driving theme along with thought linkage and this usually allows a thought disorder to become more comprehensible and for progress to be made towards a formulation and symptom management.
Certain delusions such as Capgras and Cotard can have either functional or organic origins. A full neuropsychological assessment is often necessary to rule out cognitive deficits. In the case of Capgras, which is linked to neurocognitive deficit, a combination of cognitive remediation and CBT techniques may be the most effective. In those cases where the delusion is assessed to be more determined by its psychological function, suitability will be assessed in a similar way to other functional psychotic problems.
This is a situation in which both parties will change at different rates if they are separated and treated individually. Here the partner who through separation is released from the pressure of the dominating psychosis in the other can in time be of a great help to the psychotic partner in gradually testing out the key psychotic material during homework assignments. Both partners should be included in therapy.
This dangerous delusion often arises in the setting of alcohol dependence or as a psychotic deterioration in a personality disorder where jealousy or envy has been a central feature whether manifest or latent. The alcohol condition would need to be treated as much as possible either before or alongside engaging or on the underlying belief of inadequacy at the schema level.
These require a combination of the approaches that are so well described for CBT of bipolar disorder (Scott, 2002) and that described for schizophrenia (Kingdon and Turkington, 1994; Fowler et al., 1995). Schema vulnerability can include schemas of specialness, which can underpin mania, and schemas of worthlessness, which can underpin depression. A number of schizoaffective patients hold core beliefs about specialness and worthlessness simultaneously. Therefore, both coping strategies, relapse prevention, and formulation work leading to schema level work are all pertinent to schizoaffective disorder. The coexistence of specialness and worthlessness schemas fits in with psychodynamic views of their dynamic relation to one another and indicates that self-esteem would be a central focus if longer-term psychodynamic work proves to be possible once the more extreme psychotic manifestations have settled.
Patient: I have a snake in my abdomen
Therapist: How do you know that it is a snake?
Patient: I feel it moving in my lower tummy I also feel it trying to get out (somatic hallucination) and there is a vague pain in that area of that body…
Therapist: Do you experience anything else when this happens?
Patient: Yes I smell the oil from my uncle's clothes he used to baby-sit regularly when I was younger…. (disclosure)
Here the symptom complex is linked to sexual trauma, which is worked with as under traumatic psychosis as described above.
These behave like obsessional thoughts both in terms of content (sexuality, violence, religion) and in terms of the patient's response with anxiety distress and avoidance.
Patient: The voice tells me to pick up a fork and stab the man beside me at dinner whenever I am trying to eat in the kitchen in the hostel
Therapist: How do you feel when that happens?
Patient: I feel very tense and I very quickly run out of the kitchen area
Therapist: Would you like to attempt to work with this to cope better with the voice?
Patient: Okay
Therapist: Let's look at the situation in your imagination now and see if we can cope with it a bit better. Everybody gets the odd violent thought (normalizing). These are obsessional thoughts and people hardly ever actually do these things. Having the thought is not the same thing as doing the action. Why not say to yourself that the voice is like one of these obsessional thoughts… it is just a thought caused by stress. If you stick with it then it will gradually settle down and pass over.
Patient: I have tried it in imagination and after a few extra minutes it did start to settle down
Therapist: Okay lets repeat the imagination exercise for 10 minutes every day and see how it feels by the end of the week.
The most viable early intervention approach seems to involve (McGorry et al., 1996) individual and group support with normalizing and use of basic CBT reality testing techniques as described above. The family should be kept fully informed of the strategies being used. The needs-adapted model incorporates psychodynamically informed supportive psychotherapy along with family therapy with a prominent emphasis on continuity of care.
The need-adapted model was developed by psychoanalysts. The central psychoanalytic components are (1) the ongoing detailed assessment of the unconscious psychodynamics of the case, on the basis that most psychotic breakdowns are the result of an overwhelming of the mind by unbearable affects from trauma, loss, and/or developmental strains, sometimes in a biologically vulnerable individual, and (2) establishing long-term therapeutic relationships are central to the treatment method. The psychoanalytic concepts of containment and countertransference are a central component of sophisticated therapeutic ego support until the patient is ready to take back projected aspects of the self. Other aspects of the need-adapted approach are not strictly psychoanalytic—but the essence of the overall approach is: (1) that there is a full complement of treatment resources available so that the most relevant intervention is offered at a particular phase of the therapy—need adapted; (2) low-dose medication is used as an aid when necessary in order to maintain the capacity for psychotherapeutic work; (3) the purpose of therapy is to go beyond psychotic manifestations and help the person (with assistance from the families where indicated) to attend to developmental impasses, disturbances in self and interpersonal relations and manage as full a range of affects as he or she can using the most appropriate interventions; and (4) a realistically hopeful attitude is essential and this includes an expectation that many normal aspects of living will be achieved including a capacity to work. Further details are in Alanen (1997).
This form of early intervention has given rise to the most robust medium-term durability results. For example, Alanen's latest reported cohort treated in Turku by the need-adapted method found that at 5 years 82% were without sickness benefits, 57% were in active work, and 61% were without psychotic symptoms (Alanen, 1997).
The jury remains out as to which are the most appropriate psychological strategies in relation to working with those patients with acute relapse in schizophrenia. The excellent results of Drury et al. (1996) in terms of treatment of emerging psychotic symptoms were not replicated in the more powerful and well designed Socrates study where CBT was compared with supportive counseling and treatment as usual (Lewis et al., 2002). In this study the end of therapy results showed that supportive counseling and CBT were both more effective than treatment as usual in reducing overall symptoms and that CBT was significantly more benefit in reducing hallucinations. It would certainly seem clear that a psychological treatment is crucial in the management of acute relapse to improve symptomatic scores at time of discharge. Further research should be undertaken to elucidate further the most effective psychological treatment modality in the setting of acute relapse. In many cities inpatient wards have lost their therapeutic potential and are highly disturbing environments when tranquillity and friendly unhurried environments are essential. It is to be hoped that low stimulus temporary accommodation in the community suited to the age of the patient will be more available, but much will depend on the quality of staffing (Barker, 2000).
Patients who are extremely psychotic and insightless often drop out of therapy early on. As many as 12–15% of patients with schizophrenia drop out in this way and psychological treatments cannot be further considered until a period of stabilization is achieved often requiring intensive home treatment and the use of antipsychotic medication or a period of inpatient care. Sudden jumps in insight can also lead to periods of increased depression often due to catastrophic cognition sometimes linked to the label of schizophrenia or to awareness of traumatic events leading up to the psychosis. Such cognitions need to be adequately dealt with in session or drop out may ensue. Sessions need to be tailored to individual needs working from superficial to deep and with the use of appropriate homework exercises. The use of techniques both in terms of homework or reality testing, which are too penetrating, can also lead to disengagement. It would also appear likely that certain ethnic groups have greater difficulty in working psychologically than do others. Within the brief CBT in the community study, Turkington et al. (2002) described that black African and African Caribbean patients were much more likely to drop out of the therapy than were the Caucasian patients. There is also evidence that Chinese schizophrenic patients for cultural reasons find talking therapies to be more difficult (Chan, 2003). Many patients are also very sensitive to loss and every effort needs to be made to ensure the stability of the teams and of the key staff involved that patients have the best relationship with.
It would seem therefore that psychological treatment in schizophrenia has a viable evidence base across the spectrum of schizophrenic symptoms. Certain modalities of psychological treatment alone and in combination would also appear to be viable at different stages from the prodrome all the way through to treatment resistance. We would now appear to need more carefully designed trials to get more reliable indicators as to which patients will most benefit most from which approaches, for example, psychodynamic psychotherapy and/or cognitive behavioral therapy compared with treatment as usual in chronic schizophrenia. These trials would need to reach agreement on outcome criteria and be able to identify therapist variables, including the important nonspecific components that are part of all psychotherapeutic endeavors (Paley and Shapiro, 2002). We also need to test combinations of treatment that include cognitive remediation and family therapy to find the most effective combinations. In terms of trial design there is a great need for much more in the way of pragmatic trials such as that of the Parachute Project (Cullberg et al., 2002) and the Finnish multicenter trial (Lehtinen et al., 2000), which would allow results to be more generalizable into the general clinical population of schizophrenic patients in the community. The Cullberg study is a large multicenter one that indicates that even after only 1 year the need-adapted model led to a reduction in use of inpatient beds and neuroleptics compared with a high-quality control group. The Finnish study indicated good treatment outcomes at 2 years for a whole population of first episode psychosis patients using the need-adapted approach and little more than half the patients needing antipsychotic medication at any time.
Wider implementation of these psychological treatments will require changes in the education programs for all mental health professionals and the development of robust local supervision systems and whole system management. The advances described in this chapter in relation to psychological treatments for schizophrenia have been paralleled by improvements in antipsychotic medication and by some understanding of the biological substrates involved in schizophrenia. These rapid advances herald an era of renewed hope to these patients with this most feared psychiatric diagnosis.