January - 1998

There have been so many efforts at describing what schizophrenia is, that at best, it becomes more complex and difficult to understand than it really should. Kraeplin called it a deteriorating disease entity. Eugen Bleuler called it a group of related disorders. It has been defined as a syndrome, a condition, a disease caused by one organ of the body or another, others have called it a neurobiological condition. There are those who hold that it is caused by malevolent parenting. Frieda Fromm Reichmann’s etiological theories about the schizophrenogenic mother was popular in the 50’s and the 60’s. In fact there are still some professionals who believe this to be a reality. The concepts of biochemical deficiencies, was introduced in the early 50’s. The arguments about whether schizophrenia is a deficiency or a deficit was also popular. Currently the focus appears to be an effort to explain schizophrenia as being a brain disease.

 None of these assertions have been effective in defining this condition in a way which would help professionals and other interested individuals understand it as a human process that can be seen as a logical reaction to the enormous pressures and fears that precede its eruption. This acute phase creates a sense of terror that needs to be dealt with in order to help that individual survive. We need to have some understanding of what happens to the enormous fear that comes as a function of the schizophrenic reaction. What happens to the fear? The fear that creates a sense of imbalance and great disharmony is processed through the mind of the person so that the fear is converted into symptoms and characteristics that seem to serve to diminish the fear. This leads to a growing emotional detachment from people and/or situations that are perceived by that individual as being dangerous and potentially destructive.

The patient’s reality and the perception of the professional.

When we view these patients and their protective mechanisms and their logical systems, we do not respect, well enough, the meaning and purpose of their reality and impose our system of logic and our perception of reality with the intent of persuading the patient that he/she has a completely inappropriate and/or illogical viewpoint of life. However, if we have some awareness of what creates their perception of life, then we have some understanding of their reality and as a result, we are in a better position to make a meaningful therapeutic contact. If we do not have this understanding, it becomes clear to the patient, with schizophrenia, that what he/she is facing is not understood by the professional. So to paraphrase the writings of Frieda Fromm Reichman, treatment does not become a shared experience. There is no understanding of the person with this condition and as a result of the misunderstanding, there develops around the picture of schizophrenia, in the minds of the professional and other interested people, a series of misconceptions about their condition. No wonder treatment has not succeeded well enough. There are many ideas, as I said, about schizophrenia; to see schizophrenia as a brain disease, certainly does not explain to the patient or his/her relatives any understandable idea about the condition. To see schizophrenia as a brain disease, in my opinion, is a gross misunderstanding of the process and thereby becomes confusing to the patient and important people in the patient’s life. Even if there are some changes in the physiological structure of the brain, there is no understanding of causality.

Some ideas of treatment

However, when you think of treatment and look at the history of treatment, we see that the majority of treatment over the years, has been the physical methods. Therapists, whether it be a medically oriented therapist, or a psychotherapist, a specialist in rehabilitation and resocialization should know that medication, as important as it is, does not effectively deal with delusions of one sort or another. It doesn’t in many cases, overcome auditory hallucinations. It does not serve to make contact with patients and establish a therapeutic alliance. It doesn’t necessarily overcome aggression and violence in patients. It may effect some changes in the positive and the negative symptoms of schizophrenia, but it does not overcome these conditions. So, is schizophrenia a medical condition? Is it a brain disease? What are the causes? Is recovery possible? If so, to what degree? What are some of the variables in treatment? With the psychosocial movement which has become a widely accepted form of treatment, it becomes evident that the missing link has been a psychotherapeutic approach that is able to make contact with those individuals in a manner which would make the potential for behavioral change greater. Recent years have witnessed a clear shift in emphasis in psychotherapy theory and practice in the direction of an interpersonal perspective and toward the recognition of the importance of the therapeutic relationship as a therapeutic mechanism of fundamental significance. The once tarnished concept of the corrective emotional experience of Alexander and French (1940’s) is being rehabilitated and given new life. To go even further, using the whole range of treatments with patients today, of great significance, is the corrective relational experience which allows both the patient and the treatment team to have a shared belief system. We no longer can permit ourselves to see the individual application of treatment as being given in a non-contiguous manner. There has to be a unified treatment approach to establish contact that leads to a successful outcome. Along with the psychosocial treatment models and the medications, I believe that Direct Confrontation a method of psychotherapy, that I have developed over more than forty years of my professional life, to be an important part of a unified treatment effort.

Direct Confrontation and Rapid Contact

Today, we live in a world where the consumer and financial restrictions imposed by shrinking treatment funding demands a rapid, and more concise treatment approach. I think that Direct Confrontation, a psychotherapeutic method, is designed to achieve rapid contact with the most regressed patients. The vast numbers of human beings that have been deprived of the help that they deserve have been abandoned because of the severity of their condition, have been relegated to a life of involuntary servitude. This is in fact true because of the unwillingness or the inability of the treatment world to make changes to meet the needs, that is, the specific needs of these very sick human beings. I believe that there are answers and that Direct Confrontation is a way.

The following are some of the goals of the rapid contact technique in Direct Confrontation Psychotherapy. Making contact is designed to bring about a sense of relatedness, which is the vehicle for accomplishing specific and preliminary objectives in treatment. Without the initial contact, which is the first step in treatment, there are no other steps.

 1. To quickly disrupt the patient’s illness directed and counter productive interpersonal behaviors.

 2. To frustrate the patient’s efforts to maintain personal stability at the expense of productive human contact.

 3. To discourage the patient from relying on defensive patterns leading to social isolation.

 4. To help the patient anticipate the increased levels of discomfort that may accompany serious efforts to bring about change.

 5. To facilitate the patient’s efforts to build more productive interpersonal strategies.

 6. To help the patient learn to share his/her experiences with others, thus establishing the cornerstone of effective treatment.

Many therapists emphasize a slower approach because they believe the patient is very fragile and that moving quickly will result in harmful regressions. My experiences suggest that if regression happens, it has more to do with the effectiveness of the psychotherapy, disturbing the psychotic equilibrium and not with the patient being fragile. They may have weak egos, but are powerfully defended, especially when their survival system is threatened. Regression in many cases, can be avoided, if the psychotherapist is aware of the intactness of the therapeutic alliance. If there is a weakness, or a rupture of this alliance and it is not repaired quickly enough, then the potential for regression is greater.

When the patient and the therapist have a shared belief system, dealing with some of the symptoms and characteristics of this condition such as auditory hallucinations, delusional systems and other symptoms which have become a part of the defense structure of the schizophrenic, makes the possibility for successful treatment.

 Until we meet again,
Jack Rosberg