The use of direct confrontation:  the treatment-resistant schizophrenic patient

Rosberg J, Stunden AA.  The use of direct confrontation:  the treatment-resistant schizophrenic patient.
Acta Psychiatr Scand  1990:  81: 352-358.

Schizophrenics are often labeled treatment-resistant because the psycholo-gical treatment they receive is seldom appropriate for their needs.  Spe-cialized psychotherapy for schizophrenia is available but rarely used.  Training in these methods is difficult to find.  If we are to treat schizophrenia successfully, we must rethink the treatment and training process, modify our views and teach interventions that force the patient to respond to the demands of the therapist.  Professionals must learn that change occurs because the therapist is stronger than the psychotic defenses of the patient, i.e., the patient’s resistance to treatment.


J. Rosberg, A. A. Stunden
Anne Sippi Clinic Foundation, Los Angeles
California, USA

Alastair Stunden, Ph.D., Senior Psychologist,
Anne Sippi Clinic Foundation, 2457 Endicott     Street, Los Angeles, CA 90032, USA

 
Treatment resistance in schizophrenia has long been a topic of concern (1,2).  Our failure to find a specific cure for the illness has forced us to explore a variety of treatments with each patient as we cast about for the one that is most effective.  The frustration this begets in many practitioners is almost palpable.  It is from this ground that the concept of treatment resi-stance in schizophrenia has grown.
Nor have the problems posed by the patient’s inability to respond to treatment been easily re-solved.  The question has always remained of how to cope with this apparent treatment failure.  At a prac-tical level, some kind of treatment has usually been offered, some patients receiving more, some less.  But what is made available has depended largely on the professional orientation of the specialist provid-ing treatment and the resources available to support treatment costs.
For medical practitioners, treatment resistance in schizophrenia has meant returning to a traditional medical model.  That is, some patients can be expected to recover without treatment, others are helped by treatment, and still others do not respond to treatment.  Arieti called this last group terminal and refractory, meaning that they would never be able to benefit from treatment (3).  Thus, even before the Anschluss of biological psychiatry, medical mores advised that some mentally ill patients were not only resistant to treatment, but had no real hope for recovery.
This medical perspective of treatment resistance is in contrast to that of Freud and others, who suggest that patients resist treatment to protect themselves from the discomfort of change.  This notion has its theoretical basis in the idea that any organism will engage in self-protective behavior, i.e., defensive behavior, when it experiences threat.  This concept also implies that each patient can negatively influence the outcome of treatment.  As a result, this resistant behavior must also be treated if the eventual outcome is to be successful (4, 5).
Until recently, the problem of treatment resistance in schizophrenia had not received much formal, scientific attention.  Sparked by the work of the late Philip R.A. May (6), an international symposium was convened in 1988 to address the topic.  The result was a book that offers guidelines for further research and suggestions for treatment (7).  Some consensus appears to have been reached, primarily for biological solutions.  However, the lack of attention to important psychosocial issues has resulted in a document laden with confusion and misunder-standing about the role of psychotherapy in the treat-ment of schizophrenia.
Malm, a contributor to the book, explores one such controversy.  He points out that inherent in the rehabilitation model of treatment is the assumption that effective treatment requires that patients must become as well as they were before becoming ill.  Malm suggests that this may be a fundamental error.  Our inability to achieve a particular outcome should not limit the treatment offered.  We must work with the patient with what we have available, both therapeutically and with what the patient presents.  Further, Malm suggests that the concept of treatment resistance may only mean psychological resistance to change (8).  Implicit in his position is the possibility that patients labeled treatment-resistant are not offered the kind of psychotherapy that would help them, and that patients who are labeled treatment-resistant may be receiving psychotherapy that prolongs their schizophrenic condition.
Our review of current thinking about treatment resistance and schizophrenia can have only one con-clusion.  The emphasis on biological methods has negatively impacted the development of psycho-therapy as a treatment tool. The psychological impact of the illness has been largely ignored and even effective psychotherapeutic interventions have come to have a lower priority than other forms of treatment.  Valuable psychological treatment tech-niques have been discarded, lost or not explored, and the pressing need to provide guidance to the clinician who works daily with the psychological conse-quences of schizophrenia has gone unabated.  Thus, workaday therapists still find themselves providing treatment that, at best, has not received the approval of the profession’s opinion leaders.
Without doubt, we have become limited by our respective disciplines and have refused to go beyond the strictures of our training.  We are not doing enough to treat our patients with the tools we have available.  In short, we are approaching our schi-zophrenic patients not in terms of their needs but our
own.

Schizophrenia and the treatment-resistant patient

In order to understand the practical relationship between schizophrenia and treatment resistance, we must go beyond the arbitrary symptom patterns inherent in our diagnostic nomenclature.  We must reorient our thinking about diagnosis and assess, in a different way, the abnormal psychological behavior created by schizophrenia.  We must learn to view the so-called treatment-resistant behavior of the schizo-phrenic as a survival system.
By whatever means, everyone has a need to sur-vive and achieve stability in their world.  If the world is disintegrating in a rapid and terrifying manner, human beings, similar to other animals, retreat until they reach a useful line of defense, that is, they seek a protective barrier of defenses to insulate them from the terror and chaos.  Until that happens, they con-tinue to experience acute distress and feel little relief.
The idea that the behavior of the schizophrenic may be a dynamic defense mechanism is not new (9).  However, during treatment, we must be able to dis-tinguish healthy behavior changes from the patient’s ability to adapt their psychotic defenses to the de-mands placed on them by the therapist.  If we can truly understand each patient’s defensive patterns we can help them reconstruct the meaning of their pathogenic experiences and teach them to become functional human beings.  Regardless of the inter-ventions used, when the defenses of each person with schizophrenia are understood for what they are, change occurs, and the purpose and meaning of their experience is altered and they begin to recover (10).
It is also important to remember that patients in the acute stage of the illness are too preoccupied with protecting themselves to recognize that help may be readily available.  Thus, they too, have been mis-takenly called treatment-resistant.  These patients view treatment as a dangerous intrusion that may not support their need for emotional stability.  Patients who feel like this deliberately try to protect them-selves in every way possible including violence, threats, withdrawal, autism, catatonia, and confused language and logic.  They may even try to make the therapist believe they are getting better.  Regardless of the tactics used, however, the patient in acute distress quickly learns to thwart the therapist so that additional attempts at treatment are minimal.
We should note that the behavior shown by the patient while in the acute phase has erroneously been called the product of regression.  We have observed, however, that the behavior of the patient in severe distress seldom resembles a comfortable return to an earlier, safer level of psychological or physical development.  Instead, it looks more like the disorganized behavior of any army that had been over-whelmed in battle and is seeking safety in retreat.  (11).
Because an acute episode may recur, most patients develop a survival system based on the need to flee from the terror of the acute experience.  In order to prevent such a recurrence, many patients resort to magical thinking, delusional accusations, or even successfully re-institute auditory hallucinations.  They begin to believe they must anticipate and plan for the disorganized behavior that appears in the acute phase.  These anticipatory behaviors become part of the defensive process designed to ensure their psychological safety.
The survival system patients create while in the subacute or chronic stage is more related to their character structure than to their illness.  Each patient makes choices about how best to cope with the stress of their disorder based on the totality of their prior experience.  Like the ineffective choices often made by other human beings under stress, the schizophrenic who expects acute distress usually responds in ways that appear inefficient, illogical or irrational.  Still, these tactics provide some protection, real or imagined, against the more terrifying aspects of the illness.


Who is the treatment-resistant patient?

However faulty Arieti’s concept of the terminal or refractory patient is, we must acknowledge that there may be patients who, no matter what treatment is offered, do not get better.  That is, these patients do not respond to any therapeutic intervention nor do they make any attempt to do so.  They do not even attempt to drive away or avoid the therapist.  They show no behavior that acknowledges the therapist’s existence or the existence of any human relationship.
The astute clinician will note that this definition is so encompassing that the possibility of any patient falling into this category is remote indeed.  Rarely, if ever, do patients successfully ignore and deny the intrusion of the therapist into their lifespace.  More often than not, the contrary is true.  The patient ac-knowledges the therapist by engaging in a wonderful variety of defensive maneuvers designed to drive the therapist away.
If the patient is successful in driving away the therapist, it is axiomatic that the therapist has done the wrong thing.  At the very least, the therapist has failed to recognize that the patient took steps to counteract the therapist’s intrusion.  Tactically, this is usually how treatment begins with most schizo-phrenic patients.  Whether the therapist takes advan-tage of the opening the patient offers is not the fault of the patient.  Nor is it the patient’s fault if the therapist resigns the game before it has begun (12).
The extent of the disability presented by so-called treatment-resistant patients may also vary widely.  At one extreme they may be severely regressed catatonics who lie moribund in their own feces.  Or, at the other, they may be patients who want employ-ment but are not able to get it because of the residual effects of their condition.  Without treatment, all of these patients are likely to die still suffering from some aspect of their schizophrenia.
Another important issue confounds the definition of the treatment-resistant patient.  Many patients find it impossible to join the treatment process because of the negative experiences they have had with psychotropic medication.  They feel uncomfortable when they use drugs because it is the drugs that make them uncomfortable.  They often drop out of treatment even though continued treatment is indi-cated.  One can only conclude that their resistance to treatment increases because the mental health system has failed to help them (13, 14).
At that point, it should be obvious that the concept of the treatment-resistant schizophrenic patient is am-biguous.  It has no carefully delineated categories that dictate, direct and define the interventions of the therapist.  In fact, it is so indefinite that, to confirm whether or not patients are treatment-resistant, the therapist must treat them.  That is, the therapist must be strong enough to interact with the patient so as to force submission to the therapist’s will.  Demands must be placed on each patient to recognize that there is a new energy in their life that has to be dealt with, and then the patient must be thrust into making a fundamental compromise between staying sick and getting better.


Psychotherapy with the treatment-resistant patient

Interest in treating schizophrenia with psychotherapy has not been completely extinguished in the United States (15-23).  However, the promise held out by the phenothiazines has caused psychotherapy to gradually lose the public and professional re-cognition it had achieved after the Second World War. Nevertheless, research, both here and abroad, has consistently pointed out the importance of psy-chotherapy in the treatment of schizophrenia (8, 24, 25), and that the best treatment a patient can receive does not rely solely on either chemicals or psycho-therapy.  Most studies conclude that persons suffer-ing from schizophrenia should be given some com-bination of both methods if maximum help is to be realized (26-28).
Thus, if schizophrenics are ever to be removed from treatment-resistant status, then we must re-member that psychotherapy is an effective treatment tool.  Given the present state of our knowledge, this is the only way they can make the behavioral and lifestyle changes necessary to reach a better quality of life.  In the treatment of schizophrenics, as with other patients, quality of life is measured in a variety of ways.  It may be as modest as learning to care for personal hygiene under supervision or as intricate as learning to negotiate the community accompanied by a friend.  Yet, quality of life seldom improves unless the therapist assumes responsibility for helping the patient to change.
We have little patience with those who suggest that taking such a proactive posture about providing treatment deprives the patient of the right to be schi-zophrenic.  We believe the schizophrenic patient wants to get better but does not know how.  In order to improve, these patients need an approach to treatment which acknowledges their humanity, as well as their innate desire to get well.

Interventions for the treatment-resistant patient

Psychotherapeutic interventions are successful in coping with the patient’s techniques for resisting treatment.  For example, when a female patient angrily accuses you of trying to destroy her life, her aggression must be attacked with aggression of your own, and you must help her recognize that, even though she is acting in a delusional way, she has not been abandoned.  Successful treatment requires that you remain a powerful and benevolent force in her life.
Although this type of patient needs vigorous re-minders, the patient must never be insulted or violated.  The force of the therapist’s anger should be expressed only at the delusional accusations.  This will reinforce the idea that the patient should not treat people inappropriately, particularly when a helping relationship exists.  Further, the patient must learn that the nasty behavior shown during the delusional assault will not be tolerated.  When a patient is threatening and has a great deal of anger the therapist cannot afford to be accepting of any part of the delusional system  Emphasis must be placed on helping the patient to behave in ways that will foster a positive therapeutic relationship, not destroy it.
Aggression is a problem often observed and mentioned by professionals who work with schizophrenics.  Aggression can take several forms.  In the simple case, it is a deliberate and conscious act designed to frighten the therapist into moving away from the patient.  For example, a patient may come up to you, and, in a dramatic manner, threaten physical harm.  One must remember that the patient may not be doing this in response to command hallucinations, other internal stimuli or as a function of a delusional transference.  Instead, it may be a de-liberate ploy to frighten you into leaving the thera-peutic field, thereby reducing the threat to their schizophrenic defenses.  In other cases, a patient’s aggressive behavior might be a test designed to assess your strengths and weaknesses.  For example, the patient might be looking for some kind of power in you which could offer protection from a life-threatening world.
Another issue that confronts therapists is what to do with the spontaneous associations offered by the patient.  These associations may come up in the course of the treatment session or at any other time the therapist and patient have contact.  Unlike the neurotic patient, the schizophrenic patient seldom reveals too much.  More often, spontaneity in the patient suggests a willingness to take a chance on what you, the therapist, might have to offer.  You should not be concerned when the patient’s state-ments are obscured by metaphors, symbols, distortions, neologisms and so on, nor should you be concerned about making sense out of the muddle the associations represent.  Patients reveal themselves because they feel comfortable, and the therapist should take this as an invitation to join in the patient’s world.  When offered such an opportunity you should accept.  In doing so you can disarm some of the fear the patients feel about their own confusion.
The question most therapists struggle with is whether they should respond at all to these patient contacts or wait for a more appropriate time.  In our opinion the appropriate time is now.  The quicker the response, the quicker the alliance and the more re-sponsive the patient will be to treatment.  In all of these cases it does not matter how much contact you have had or how long you have known the patient.  How you choose to respond will be decided by the freedom you feel to exercise your creative intuition, and to act spontaneously and honestly to the patient’s cues.
Every patient wants to tell someone their story.  This story may be told logically, metaphorically or without any apparent sense at all.  One patient we were treating became annoyed because we com-plained about his rolling around maniacally on the floor while we were talking.  The patient defended this behavior and helped us understand what he was doing.  He asked us if we had ever known what it was like to be afraid to put out a cigarette in an ashtray, or what it was like to not be able to walk from one room to another without worrying about whom you might meet there.  He told us we were wrong to criticize him for sleeping late because that was the only way he could reduce the stress that produced the acute exacerbations of his illness.  Finally, when we heard his story, he started to get better and he was able to sit in a chair.
Of course, there are certain negative signs to be aware of during this process.  For example, you may note that self-disclosure is accompanied by increas-ing mania.  If this happens, the therapist is well advised to effect closure.
Many therapists complain they cannot do therapy with people who won’t or can’t talk to them.  In these cases, as with the others, the therapist must be proactive and not reactive.  Taking charge of treat-ment does not mean, however, that the therapist ignores the behavior of the patient.  Rather, the therapist must integrate the patient’s behavior into a pattern that establishes a therapeutic alliance.  For example, with one male patient whose major defense was his magnificent command of word salad, we tried to create a dichotomy between his crazy words and our sane words.  The patient’s anxiety about the consequences of speaking sanely was interpreted to him.  He was told that if he talked sanely he might get very frightened.  We also reassured him that he didn’t need to worry about what would happen if he got sick again because we had no expectations for him and we would keep him safe.  He was told that the choice was his.  We also focused him on our own discomfort because we experienced so much con-fusion when he talked to us.  Then, through paradoxi-cal interventions suggesting how powerful his speech might be, we gave him the opportunity to exercise control over us and hurt us if he wanted to do so.  He chose not to do this and is now beginning to risk being understood when he talks.


Training the therapist to treat schizophrenia

All of us experience a wide range of feelings when we approach the treatment of a new patient.  These feelings are really energies we must use to effect a therapeutic alliance.  The patient empowers us to apply these energies with more or less confidence depending on who we are and who the patient is.  For instance, all of us have felt incapable of treating a patient at one time or another.  That we feel this way should never permit us to believe that the patient is incapable of responding to treatment with someone else (29).  Yet, far too many therapists believe they have more than sufficient experience to decide who will benefit from treatment and who will not.  In dealing with schizophrenia this assumption is unfair and unwarranted.  The illness itself fosters patterns of symptoms that are not found in our everyday human experience.  Further a treatment approach that works with one patient seldom works with another.  Because of these kinds of problems, specialized training in treating the schizophrenic patient is mandatory before the psychotherapist can begin to approach treatment with confidence.  It is not surprising that therapists without such training describe schizophrenics as unresponsive, inacces-sible, difficult to treat, or personally frightening.
We believe that most professionals educated as psychotherapists have received little or no training in the use of psychotherapy with schizophrenics.  With few exceptions, psychological training centers at major universities have been coopted by biological psychiatry.  And, almost everyone has lost sight of the simple idea that much of the schizophrenic’s maladaptive behavior can be modified successfully using psychological methods that will improve the patient’s quality of life.
Traditional psychoanalysis has not suffered from this problem.  Early in the development of the analytic technique, Freud recognized that it was not suitable for the schizophrenic patient (30).  Freud was also critical of other analysts who treated schi-zophrenia because the analytic model did not fit the disorder.
Nevertheless, Freud’s theory of human develop-ment has continued to be used by many as the rationale for treating the person with schizophrenia.  This approach has several limitations.  First of all, it tends to focus solely on the intrapsychic conflicts of the patient to the exclusion of interpersonal and family conflicts (31).  Also, the methods employed do not encourage the psychoanalytically oriented therapist to take charge of the patient’s maladaptive behavior.  This, in turn, keeps the therapist from impacting the patient so that positive change will result.  Further, this treatment model does not sanction the development of dependence on the therapist.  This dependence is necessary if the schi-zophrenic process and its attendant symptoms are to be effectively controlled.  We must remember that, for the schizophrenic, change comes about because the therapist imposes it. (23).
What then is the approach needed to work effec-tively with the schizophrenic patient?  Thomas Malone perhaps captures it best when he suggests that if one is going to do psychotherapy with schi-zophrenics one should have as few preconceived notions as possible.  Certainly no one would accuse Malone of advising that the schizophrenic patient be treated with calculated ignorance.  He does believe, however, that there are almost no data points to guide treatment beyond one: the requirement that the therapist engage in tactics that disrupt the schizo-phrenic process (32).  The principle is an important part of the direct confrontation approach to the psy-chological treatment of schizophrenia.
We have also found, as did Malone, that good psychological treatment can be taught successfully to experienced and inexperienced therapists if they are able to relax their prior beliefs about psychotherapy.  When they learn to work outside of fixed con-ventions they find it easier to express themselves spontaneously and intuitively.  When they function without preconceived ideas they can concentrate on the most important aspect of treatment; forming a relationship with the patient rather than digging in to the verbal content the patient presents.
Inexperienced and untrained therapists have greater limits than experienced and untrained therapists.  Their inexperience prevents them from managing the treatment process so as to be helpful to the patient.  They need guidance and the opportunity to discuss treatment issues so they don’t back away either out of fear of making mistakes or in the false belief that their intuition is all they need.
On the other hand, the experienced and untrained therapist who has a good therapeutic relationship with a patient does not often recognize the patient’s inability to exercise appropriate social controls over their impulses.  These therapists become overconfi-dent and ignore the patient’s pathology.  They as-sume, unrealistically, that the therapeutic alliance is enough to persuade the patient to act in a socially acceptable way.  They have not learned enough about the impact of the schizophrenic process on the patient’s thinking and emotions, nor do they under-stand that an active treatment process inevitably creates wide fluctuations in the patient’s behavior that the therapist must control if the patient is to be protected.
Further, we have observed that when therapists stubbornly insist on hanging on to their prior beliefs about therapy they usually interact with the schi- zophrenic patient in a manner that drives the patient away.  They then blame the patient for resisting treat-ment and see no need to examine the impact of their own faulty approach.  In part, these therapists think this way because they are not willing to make the commitment necessary to help the patient recover.  From this we conclude that people who rigidly insist on maintaining their early beliefs about treatment don’t really want to work with schizophrenics.
From our observations we have developed a pattern we feel is typical of unsuccessful trainees.
1.They believe they are right and the patient wrong.
2.They believe they must always correct the dis-tortions of the patient so as to reduce the patient’s symptoms.
3.They ignore the importance of finding something in the communication of the patient about which both they and the patient can agree.
4.They measure the health of the patient, and thus their own competence, by the presence or absence of schizophrenic symptoms.
5.They believe symptoms are the sole rationale for their therapeutic interventions.
6.They have lost respect for the integrity of the patients as human beings simply because they are schizophrenic.
7.When they or the patient becomes anxious they rely on medicine instead of themselves.
8.They believe the patient is beyond hope.
9.They believe that the patient suffers from a de-teriorating disease that does not justify the cost of treatment.
In summary, we feel it is fair to say that most professionals have been too frightened by schizophrenia and schizophrenics to treat them at all, or, if they have, their countertransference reactions have typically resulted in major therapeutic error.  The main problem in treating schizophrenics with psychotherapy is not the treatment-resistant patient: it is the treatment-resistant therapist.
Therapists who want to work with people with schizophrenia cannot expect to do so without additional training and experience.  They will be able to build on their past experiences only if they are open to the new challenges schizophrenia presents.  They must be willing to risk and take chances and try different tactics to see what works and what does not.  In our present state of knowledge, treating schizo-phrenia is different from treating any other kind of disorder.  Yet because we are dealing with human beings, the underlying principles are the same.  Understanding how and when to apply them, how-ever, is not something that can be taught by rote or formula.  Therapists whose therapeutic frame only requires them to listen objectively so as to encourage the building of the transference may find this approach to be beyond them, and therapists who have not had any experience with psychotherapy as an influence process may find treating the schizo-phrenic patient too taxing.
Therapists must learn that the task of therapy is to redirect the patient into behaviors more consistent with what is normal.  Even though a cure is not yet possible, we must learn to accept that patients can be changed and the quality of their lives improved.  We must also learn to accept the burden of treating the schizophrenic patient and create an atmosphere that will help them become more acceptable to themselves and the world we all live in.

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