January 1999

The following is an evaluation of four treatment sessions with an individual with a diagnosis of Schizophrenia. The video tape was done by me beginning in 1984 and ending in 1987. It is a very clear discription of the use of Direct Confrontation in the successful outcome of treatment. This video tape is for sale for those in the United States who are interested, the price of the tape is $75.00, including handling and shipping. For those outside of the U.S., requiring a PAL system, the cost is $100.00 including handling and shipping. Please allow four to six weeks for delivery, send your check/money order in U.S. dollars to Jack Rosberg, 2457 Endicott Street, Los Angeles, CA 90032. Or you may call Jack Rosberg at (323)226-1411. Bear in mind that this is one of about 100 titles that can be purchased if the interest is there.

This tape shows some of the basic and critical steps in the use of Direct Confrontation Psychotherapy in the successful treatment of schizophrenia. Using excerpts taken from four treatment sessions with the same patient of his techniques as a vehicle to produce positive and lasting change in a severely disturbed schizophrenic patient.

Introduction:

The first segment (September of 1984) shows the patient whose psychosis has not yet been successfully broached. In the second segment (October 1984) we see changes taking place that reflect and important modification in the patient’s delusional thinking and in his relationship to the therapist. In the third segment (May 1986, we see the depression that comes with the loss of the psychosis. And, in the last segment (February 1987) we see that the patient’s problems are now essentially neurotic in nature and that he is no longer schizophrenic.

The patient is a 26 year old who has been mentally ill for about eight years. He is a high school graduate, has had some college, was fairly successful throughout his high school career and showed few signs of severe disturbance prior to his first break in 1979. Hospitalized several times before coming to the clinic, in May of 1984, the patient suffered from classic psychotic symptoms including persecutory and grandiose paranoid delusions, auditory hallucinations, the belief that thoughts were being planted in his mind (thought insertion) and that others were reading his mind against his will. During his stay at the clinic, he received low doses of medication (Halperidol 5 to 50 milligrams) and has gone for months at a time without any medication at all.

The patient presently lives in the clinic’s Independent Transitional Living Program where he is responsible for his own apartment, preparing some of his meals and generally taking steps calculated to move him back into the mainstream. His goals for the future are not yet defined but these issues are included as topics in his current treatment.

Segment I

In the first segment (September of 1984) we see the severity of the patient’s symptoms, and most importantly, his beliefs that he will be safer to resist the changes being advocated by the therapist than to accept them. (Most patients go through this phase, believing firmly in the old maxim that "the devil you know is better than the devil you don’t know"). As a result, he tried to keep Jack at bay by being angry and blaming and at several points even tried to manipulate Jack into agreeing with the absurd delusional material. It is important to note that Jack does not get into a ‘power struggle’ with the patient but instead holds his ground and sticks firmly to the position that he (Jack) has a better grasp of what is real than the patient does.

This particular Direct Confrontation technique demonstrates how important it is for therapists to have a clear understanding of their own relationship to reality and an ability to express that understanding in ways which do not overwhelm or upset the patient or disrupt the therapeutic alliance. These points in the treatment process are crucial, because, if they are not handled successfully, the patients can be lost to treatment, or can even be encouraged to build other negative character traits which will make the continuation of treatment more difficult.

Segment 2

In segment two (October 1984) we see that the patient’s resistance to change has been broken through. The patient is still reluctant, however, to acknowledge the role of the therapist as a change agent. The patient admits to being "sick" but continues to use the delusional material as a smoke screen to prevent a closer relationship with Jack. Jack continues to confront the delusional material but this time includes dynamic statements as part of his intervention process. This exploration of the patient’s ego and motivational structure is designed to help the patient begin to recognize that the psychosis has a purpose other than just ‘being crazy’. This stratagem will be brought more and more into play as the therapist judges the patient is prepared to handle it.

It is also clear, despite the patient’s protests to the contrary, that Jack is now fully in control of treatment, and that a strong therapeutic alliance exists. Even at the end of the segment, Jack continues to exercise his control over the treatment process by giving the patient permission to be ‘crazy’ if he still needs to do that.

Segment 3

In segment three (July 1986) we see the depression that is typically experienced by patients when they ‘lose’ their psychosis. The patient, in effect, has lost his identity. He now no longer knows who he is as a person even though he can reasonably and accurately differentiate between reality and insanity. He remembers the experiences he has been through, recognizes that he has been ill, but does not have sufficient ego strength or self confidence to pick up the pieces and move ahead with any sense of confidence.

It is at this point that therapy takes on a reconstructive character. The patient must be allowed, slowly and carefully, to put things back together so that he can successfully leave his illness behind and move forward into a different life. We see Jack reinforcing the patient’s grasp on reality by making him remember the inappropriate aspects of his illness. We see the use of paradoxical statements calculated to more the patient into taking a definitive stand about what is real and what is not.

This point in treatment is also crucial for the patient because it is at this time that the patients is at his weakest and most helpless. Thus, it is imperative that the therapist have a firm grasp on his/her own reality, as well as on what the patient’s needs are and how best to provide for them.

Segment 4

Finally in Segment 4 ( February of 1987) we see that the patient has gained insight into his illness; has become a person who can talk about himself in a comfortable and easy way; is now someone whose affect and thinking is virtually indistinguishable from those of the average person; is someone who has developed enough ego strength so that the therapist can begin to rely on the patient to be more active in the recovery process and so on.

The kinds of interventions being used by Jack in this segment (including self disclosure), are more typical of those used in dealing with neurotic patients. It is also evident that the relationship between the two men has changed. Unlike the earlier sessions, a sense of equality now exists between them and it has become possible for each of them to have more respect and trust in the other’s judgment.

Until we meet again.

Jack Rosberg