Special Edition  -  Lithuania
Jack Rosberg, Executive Director of the Anne Sippi Foundation

In the early spring of 2004 my wife Ann and I went to the Baltic States where we introduced some of the more active methods of psychotherapy.  We spent most of our time, in Lithuania.  Two weeks in Kaunas teaching graduate students at the University, about methods of psychotherapy and psychosocial rehabilitation with individuals who had a diagnosis of schizophrenia.  The next several days I gave some presentations at the Vilnius Mental Health Center and also worked with a schizophrenic patient who had been in and out of the hospital many times. 

The conferences in Kaunas and Vilnius were arranged by Dr. N. Gostautaite Midttun.  Dr. Midttun who was a gracious hostess, she made our stay rewarding to us and also to the students, psychiatrists, psychologists and other mental health professionals who attended the presentations.  We found that Dr. Midttun to be a very intelligent, curious and enthusiastic supporter of our efforts.  We found that many of the professionals who attended were hungry for new directions.  The response was most gratifying and even now we continue to receive letters and e-mail correspondence from some of those who attended the teaching program in Kaunas and the seminars and workshops in Vilnius. 

We thank Dr. Midttun for her continued interest and those people who participated for their wish to explore newer ideas. 

The following is an evaluation of the methods of Direct Confrontation by Dr. Midttun.

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Use of Direct Confrontation for Making Contact with the Patient Who is Going Through an Acute Psychotic Episode.
Written by N. Gostautaite Midttun, M.D.

In spring 2004 the Vilnius Mental Health Center had the opportunity to meet psychotherapist Jack Rosberg, (USA), who introduced the method of Direct Confrontation and demonstrated the method with videos and a session with a schizophrenic patient.  Jack Rosberg is a psychologist who studied psychotherapy with John Rosen, M.D. and has been working with schizophrenic patients for 50 years. 

This Article provides an overview of the main principles of Direct Confrontation for patients undergoing an acute psychotic reaction.  Jack Rosberg states that the method is strongly based on intuition for defining limits of acceptable behavior and is able in a creative way to get through to the patient’s consciousness.

Direct Confrontation stems from eclectic psychotherapy and belief that psychotherapy is effective even without knowing the etiology of schizophrenia.  Lamb (1981) says that psychotherapists should encourage patients to use the healthy part of their personalities:  “When treating schizophrenia it is important not only to reduce psychopathology, but also to develop the healthy parts of the personality even in severe cases.  Partial remission is an acceptable and preferable treatment goal”.  Those who use the method strongly agree that the belief of the psychotherapist in his ability to help is of extreme importance.  The method asserts that fear and misunderstanding from the environment and the helplessness of professionals increasingly isolates the patient, who fearing rejection continues detaching themselves from meaningful relationships, hiding behind psychotic symptoms.  The schizophrenic process is viewed as a survival mechanism and recurring symptoms serve to insure isolation, with the hope of reducing pain and the fear of rejection. 

Central to this method is the contact between the patient and the professional.  If the patient refuses to engage in contact, the professional must establish a connection, forcefully if necessary, even if the therapist risks a negative response from the patient. 
Any, even a negative response, is most important since the therapeutic alliance and the patient’s will to get well depends on it.  Rosberg considers that psychotherapy of schizophrenia is a suppressive effort pushing the content of the unconscious back, without trying to understand and explain it.  Psychotic process is suppressed through the provision of ego limits and the enhancement of defense mechanisms.  Rosberg asserts that the schizophrenic patient does not attempt to communicate with the psychotherapist, but rather avoids contact.  While the patient is trying to sustain the distance between him and the treatment, the psychotherapist is trying to make contact and establish a strong relationship with the patient seeking to modify his psychotic behavior and establishing a framework for new types of engagement with the environment.  Frequently this happens through the intense struggle between the patient and the psychotherapist.

There are several stages in this process.  During the introductory stage the psychotherapist is trying to gain the attention and make contact with the patient.  Even if it means provoking negative reaction from the patient, while in the meantime the patient is trying to keep the delusional system intact and stable.  This at times requires strange and unusual behavior patterns from the therapist, provoking and adequate response from the patient.  The second stage is devoted to breaking into the delusional system.  The patient is provided with the opportunity to recognize and name unacceptable behavior, label it as being abnormal and “crazy”.  In the third stage the goal is to effect catharsis, by demanding that the patient recognize that he is crazy.  The patient is asked to repeat “I am crazy” until the catharsis is achieved, then restructuring and resocialization can begin.  Restructuring and resocialization begins when the patient is able to communicate with the psychotherapist without demonstrating psychotic symptoms.  During this period the patient is encouraged to understand the reason for his pain and suffering, regain family and friends, and improve independence.  During this stage the patient at times is transferred to another therapist in order to reduce the intensity of the relationship. 

During the psychotic period achieving contact with the patient can be difficult.  Patients act strange and often inadequate; they can become excited and aggressive, and difficult to reach.  Therapy without this contact is not possible, but it is wrong to neglect the patient’s opportunity to have therapy, because this critical period therapeutic intervention can effectively disrupt abnormal psychotic adaptation and socially unacceptable behavior. 

Direct Confrontation focuses on a healthy therapist – patient relationship.  The therapist demands “normal” and remission oriented behavior, while continuing to provide support, respect and a positive attitude.  The therapist expresses emotions not only positive, but irritation over delusional behavior is also expressed.  The patient’s aggressive behavior is met with an aggressive response from the therapist avoiding outright abuse.  Sick and healthy parts of the patient are clearly defined and separated emphasizing that delusional behavior will not be tolerated, since the therapist finds the patient a valuable human being.  Direct Confrontation does not encourage insulting patients – the negative response of the therapist is directed towards the illness and the psychotic symptoms and not at the person.  Yet when the patient blames the therapist for plotting against the patient, this delusion is met with indignation.  Direct Confrontation is a method that avoids therapeutic neutrality; attitude of the therapist to the patient is clearly stated.  The therapist is a central force for achieving remission, and has to be in full control.  According to Rosberg, if the patient is allowed to determine the pace and direction of the therapeutic process psychotherapy is ineffective, because the patient is interested in keeping a stable delusional system.  This method challenges attitudes, established behaviors and beliefs of the patient.  Jack Rosberg demonstrated the method through videos and actual consultation.  He patiently listens to a reiteration of the patient’s successes and unexpectedly to the audience of specialists and the patient himself, said: “this cannot be true since you are locked up in a psychiatric hospital for several months.  That does not sound like success you must be doing something wrong.”  Irritation and confusion over such an unexpected assessment releases energy necessary for the disruption of the delusional system and promotes positive change.  Direct Confrontation is an active method – it attempts to provide an explanation for patient’s problems and possible solutions: “you have a problem with dependency, which you have to acknowledge and decide if you want to get better, rather than deceiving yourself with an unrealistic vision of yourself, thinking that this lengthy stay in the hospital is just a meaningless mistake.”  The patient has to understand that his avoidance of the problems delusional beliefs and behavior will not be tolerated.  If the patient is refusing to talk, the therapist has to be active, instead of ignoring the patient’s behavior.  If the patient doesn’t talk, then the therapist talks, creating frustration and disrupting the stability of the psychotic adaptation, refusing the patients attempt to isolate themselves. 

Using this method the therapist rejects the patient’s illness, at the same time respecting the healthy parts of the personality.  It is important to be careful, as not to encourage guilt in the patient, because they did not get ill with schizophrenia willfully.  Accepting disability and limitations caused by schizophrenia, the therapist should help the patient to gain control over their own lives and provide hope and future perspective.  One of the important goals is to enhance the patient’s curiosity – it has to be interesting for the patient to enter into the therapeutic alliance.  The basis for psychotherapy is verbal communication and though therapy begins with conversation, not every conversation is therapy.  The therapy process has to be soaked in respect and the feeling of safety for the patient.  The patient has to feel that the therapist will protect him/her from the dangers of the illness, because only in a safe environment will the patient assume responsibility for their actions. 

Interesting and practical ideas evolve in many different places and times.  Participants of the workshop have commented that in Lithuania the method might have been called
A. Alekseichik Method, which maybe at different times and situations might be presented in the USA in a similar fashion.  This method created conflicting feelings and thoughts among participants posed new questions yet is likely to find its place among therapeutic instruments used in Lithuania.