ABOUT SCHIZOPHRENIA

A Newsletter of the Association for the Psychotherapy of Schizophrenia, International and The Anne Sippi Foundation

NOVEMBER 1997

By Jack Rosberg
One of the reasons that we have so many people hiding under bridges, people walking the streets and people who are being shuffled from psychiatric hospital to psychiatric hospital and warehoused in board and care homes is because of inadequate treatment from people who do not want to treat them. Then they are seen by professionals as being treatment resistant. What does it mean when a person does not respond to one treatment modality or another, is that necessarily the criterion for that label, treatment resistant? To go on, if some people with schizophrenia do not respond to medication, some medications, all the older medications or some of the more traditional psychotherapies and/or psychosocial measures that are not adapted to fit their specific needs, as individuals, are they treatment resistant? They are not responding to treatment that is prescribed and applied by mental health professionals, so they are treatment resistant. In a book that was published in 1988 called "Treatment Resistance in Schizophrenia" edited by Dencker and Kulhnek which was a product of a workshop conducted by seventeen distinguished mental health researchers, from many parts of the world, in Stockholm in 1988, had as its goal to look at this reaction to treatment and find some ways of explaining it. In my opinion, one of the most reasonable presentations published in the book was given by a friend and colleague of mine from Gotesborg, Sweden, Professor Ulf Malm. The title of his presentation was "Good Routine Treatment in Schizophrenia. To quote the article "Good Routine Treatment in Schizophrenia, means achieving change in symptoms, social role performance and interpersonal contacts - in a way that is individually planned for each patient. Models of rehabilitation that rely mainly on individual psychotherapy or drug treatment alone have proved to be insufficient. Whereas most treatment episodes are now relatively short, rehabilitation requires long term changes in symptoms and quality of life, but even the general goal of rehabilitation as it was understood in the 1950’s - that patients should become as well as they were before falling ill - needs to be reassessed. Instead, rehabilitation ought to be directed towards improvement in the recovering patients adaptive capacity; but at the same time, we have yet to learn how patients improvements in social skills can be effectively transferred from the hospital milieu into natural social fields. This implies that a detailed evaluation of the various handicaps should be carried out in the actual situations where each patient has expected roles - the family or the peer group, neighborhood, public areas, such as a grocery shop or a place of work, and any relevant sub-culture. However, these expectations - as well as the premises on which rehabilitation is based - can change over time; handicaps may not last forever, social support might increase, or the situation might worsen. Therefore, the concept of repeated cycles of rehabilitation may be useful; this derives from the fact that as earlier goals of change are achieved and stabilized, new needs and goals evolve, either on the part of the patient or his environment".

In discussion with Professor Malm, we both concluded that the important issue was not treatment resistance, but resistance to change with the person suffering from schizophrenia. Change represents a tremendous threat to those individuals so they struggle against making changes in treatment. Psychotherapy which has as its main purpose influencing behavioral changes in the patient whatever their condition might be, always encounters resistance and it is our responsibility to overcome this resistance every time it appears in treatment. What our conclusion was, is that the treater, not the patient, is treatment resistant.

I published a paper with one of my associates in Acta Psychiatrica Scandinavia in 1990 about treatment resistance in schizophrenia. We concluded that with the veteran or the long term schizophrenic, the professionals have retreated from them because of the complexity of this condition and they, the professionals, have come up with many excuses to avoid treating these individuals. But let’s be frank, we always seem to blame the patient for not succeeding in treatment. They feel like failures as a result of unsuccessful treatment and we never really seem to assume the responsibility for these failures. We need to look at ourselves much more critically than we have in the past, so, that whatever the causes of failure in treatment are, we should be able to identify these causes and overcome them. Let us bear in mind one reality, we also are resistant to change. Imagine ourselves seeing a patient in the early part of their treatment and implicit in our contact with them is the message they need to change and if one looks closely at them, one can sense that they also feel the same about us, that is, when are we going to change some of our outdated methods of treatment that they have experienced. Frequently, during the history of their treatment experience, many patients are exposed to treatment measures, such as medication and psychosocial intervention methods of treatment, which they do not respond to. In that sense, it is fair to call their reaction as being treatment resistant to that treatment method which has failed to meet their needs. That should not at all suggest that other treatment directions other medications, other psychosocial interventions could not meet their needs and help them make life style changes. Again, I believe it is only reasonable for people to understand the true meaning of treatment resistant as being that treatment which doesn’t effect changes in that person with schizophrenia. With that in mind, I think that it is only logical to explain the failure of the treatment rather than the failure of the patient responding to treatment. Also, perhaps it is necessary to repeat myself in stating that resistance to treatment is not treatment resistance. Resistance is very often a conscious and deliberate effort on the part of the person to avoid change because change represents a threat.

We need to look at this phenomenon on the resistance to change as part of the human process which effects all people in some fashion. The idea of change provokes fears and anxieties in most people, but when it comes to treatment it certainly does express itself both with the patient and the person who should stimulate change. Both therapists and patients want to be the way they are, because it is more comfortable.

What is schizophrenia? Is it beyond a series of symptoms and characteristics? Has it been defined adequately? How can it be defined in a way which makes it possible to treat this condition with some understanding of what goes on in the process? Is it a brain disease? If we say, to the patient, that diabetics take medication and lives with that condition all their lives, and you have schizophrenia, like the diabetic, you will need to take medication for the rest of your life. That doesn’t sound, to me, like a very optimistic statement. It is the responsibility of the psychotherapist doing treatment to help the patient establish a feeling of hope, so they can feel that they can achieve an independent life style and improve the quality of life. These individuals do and can re-establish themselves in a way which makes their lives more meaningful and rewarding to them. In order to help these individuals come to this conclusion, we have to find a way of making contact with them. That is the first step. How do you make contact with somebody who is apparently illogical and has all kinds of frightening ideas and strange kinds of communication? How do you make contact with them rapidly enough so that as you support that contact, you effect a therapeutic alliance which is the context wherein all treatment takes place? There is no treatment without this, there is no psychotherapy. The therapeutic alliance applies to anybody who has any kind of contact and/or relationship with the patient, whether or not it be a psychiatrist who prescribes medication, a psychosocial rehabilitation specialist or a psychotherapist. The alliance and transference are not the same, the alliance is based on reality and the transference is an unreality.

Let me go back to the idea of schizophrenia and what it is. Some years ago, I defined it in order to clarify my understanding of the nature of the disorder, which made it easier for me to approach it. I saw the acute reaction as a terror syndrome. I saw the individual as a terrified person who suffered a dissolution of their identity. A disintegration if you will. They feel they hang between life and death with a tremendous amount of fear. When this happens in the acute phase, they are hospitalized typically and they are given medication which is designed to stabilize these individuals so that other treatment methods including psychotherapy, can be initiated, with a greater degree of success. If that is true, that this direction is the way to go, how come we have so many people who are out there still so very sick requiring some kind of continued care. In many cases, they retreat to a place and only to a place where they can develop and surround themselves with a series of workable defenses. Then schizophrenia becomes purposeful, it has some meaning, it has a logic, even though it is more primitive than the logic we use; it has a language of its own. Schizophrenia is simply a survival system, that is what I see it as being. Since when they retreat, they feel increasingly comfortable even though they are not perfectly comfortable, they are reluctant to yield their system and they do not want to be approached and they will do everything in their power to keep you at arms length.

Bear in mind this enormous fear, this tremendous anxiety and this feeling of annihilation is processed into symptoms and the symptoms also serve to reduce the fear and anxiety in that individual How do you approach them, what do you do with someone who does not want to change, who thinks that they are OK because they are more comfortable? How do you approach them, in view of the fact that they have found a way of surviving in a world that they have perceived as life threatening? I believe that we do not understand well enough that their reality, no matter how unreal and/or bizarre it appears to us is in fact, a reality to them and they will cling to it, to this reality as tenaciously as they can in order to sustain the survival system that they were forced to establish.

Let me tell you about John Rosen and compare some of his ideas and methods with Milton Erickson. Rosen was an interesting contributor a man who had the capacity to make rapid contact in a very meaningful way with the most regressed patients. This was confirmed by Freida Fromm-Reichman and others. During the 1940’s as a resident in Brooklyn State Hospital, he worked with a number of patients who suffered from catatonic excitement. It was a terrifying phase of catatonia which at that time led to death. He was able to sit with them and after awhile he was able to enter their delusional system and make interpretations that resolved the crisis and they survived. This was no small feat. Out of his early experience grew some of the theories and methods of Direct Psychoanalysis. He claimed his theories were an extension of the Freudian model and based his approach to schizophrenia on the oral level of development in the person with that condition. He considered the person with schizophrenia to be a product of malevolent mothering. He said that the mother of schizophrenics had what he called "a perverted maternal instinct". If you are curious about Rosen’s work, I recommend you read his book, "Direct Psychoanalysis".

In my work with Rosen, this perception of the etiology of schizophrenia became increasingly irrational to me as a result of my experience with the patients and I took another direction. However, Jay Haley in his early years, when he worked with Gregory Batson, et al, at Palo Alto was influenced by Rosen and his theoretical ideas and used Rosen’s approach with a schizophrenic patient he was treating psychotherapeutically. The patient in question claimed that, every time he ate, he felt like he had cement in his stomach. Using the Rosen approach, he made interpretations on the oral level, which did not succeed. Then he asked Erickson, who suggested that he go to the hospital cafeteria and sample the food, which he did and he found the food to be almost inedible. It was quite clear that the patient’s complaint was based on reality. In my opinion the theories expounded by Rosen had very little to do with what happened to the patient.

I saw Rosen as a clever, commanding, forceful psychotherapist, whose presence was responsible for the changes that happened to the patients that he treated. His therapeutic strategies were good, however, his theories had nothing to do with what he did and as I have stated many times what he did, he never said. During his research at Temple University in Philadelphia, Pennsylvania in the late l950’s and 1960’s, his work was viewed and reviewed by a number of excellent professionals, such as Eugene Sheflin and O. Spurgeon English who were able to distinguish the therapeutic elements that represented Rosen’s contribution. Whether his results were what he said they were, was secondary in my opinion, to the dynamic effect it had on the psychotherapy of schizophrenia. To quote Lawrence Kubie, who said "that even if he did no more than shake people out of their complacent attitude, he made a contribution".

To continue with an approach used by Erickson, who recounted his work with a hospitalized schizophrenic patient. The patient claimed he was Jesus Christ. There are many people in the mental health field who do not believe that you can overcome delusional systems without having a serious negative effect on the patient, that is to say that the patient will replace one lost delusion with another delusion. This is an apparent absurdity. Erickson approached this patient and said that "I hear that you say that you are Jesus Christ". The patient said "Yes I am". Erickson said to him, "Would you please build me a good bookcase, I hear that you are a good carpenter". The patient had to comply and he did build that bookcase. When he had finished he no longer claimed to be Jesus Christ. There are many ways to overcome delusional systems. To say that it cannot be done, is only a reflection of that psychotherapists abilities in treating schizophrenia. In future Newsletters, I will make an effort to describe some of the methods that I use and have used over the years to overcome delusional systems.

The rapid contact which I think is critical in establishing the therapeutic alliance, is critical in effecting behavioral change. I am going to express some thoughts about what a therapist needs to do in order to accomplish this goal. However, in view of the growth of managed care, I think that it is important to understand that it is possible to develop ideas that are brief and more concise to allow you into the life of the patient. The first goal is to disrupt, as quickly as possible, the patient’s inefficient interpersonal behavior, to frustrate the patients misplaced efforts to maintain a stable and predictable world. To discourage the patient from relying on inappropriate defensive patterns. To help the patient anticipate increased levels of personal discomfort.

In the acute phase or during the early onset of schizophrenia, the common approach is to stabilize the patient with medication. Very frequently the level of comfort attained by this procedure leads to a premature discharge from treatment and subsequent relapses. However, if the patient does continue in treatment it becomes clear that the energy for change lies within the anxieties of the patient, so therefore the anxiety of the patient has to be increased in order to effect a resolution of the basic components of the schizophrenic crisis.

Bear in mind that if the patient becomes comfortably imbedded in their condition, effecting change becomes increasingly difficult and of course the resistance to change becomes greater and the efforts of the psychotherapists are effected by the amount of resistance and the methods of resistance exercised by the schizophrenic patient, because they, the patient, is afraid of going through the same crisis that they felt in the initial phases of their condition. They do not want to change, because change equals not only pain, but is, in their eyes, tantamount to death. So their tenacity in clinging to their schizophrenic solution, with every ounce of strength, every cunning and every defensive strategy that they have at their disposal. The more we try to help them and also the more we fail in our efforts, the greater their armamentarium of strategies designed to help them sustain their condition grows or increases.

So to return to the acute phase and/or the early onset, the fear and the anxiety of that condition, makes those individuals more accessible for a therapeutic resolution because the pain of that condition makes that individual reach out for help. But sadly and tragically in many cases, we do not have trained psychotherapists who are able to resolve that crisis. If that could happen, it could be a stopping point for the deterioration in schizophrenia and subsequent therapeutic efforts would be able to resolve that condition for longer periods of time if not permanently.

As they reach out in desperation for our help, that is, I believe the best time to enter into their world with them and share their life well enough to convince them and to persuade them that we are going to keep them safe from their annihilation fantasies and their great fear of destruction. If we can convince them, that we are there to keep them safe, to keep them out of harms way, then I think that we have a better chance of making the kinds of inroads that we need to make in order to effect the behavioral changes that need to take place in order for them to recover from that condition that we call schizophrenia.

There is no recovery without behavioral changes. There are no lasting changes in that person who is treated by insight oriented psychotherapy, insight is not enough. There are many patients who have been through many psychotherapies, which have not succeeded in helping them improve the quality of their lives, but have given them a great deal of insight which they use defensively and instead of these insights helping them change their behavior, it serves to perpetuate their condition. Of course we are talking about that person who has a long history of schizophrenia. When you undertake treatment with that individual, implicit in treatment, is that you the therapist, expect the patient to change as a function of your efforts. If you continue to approach the patient in a way which is comparable to the approach made by his past therapists, the individual who has that condition, looks at you and realizes that there is no chance that changes will take place, unless the changes begin with the therapist.

Psychotherapists need to be as much aware of themselves as they are of the person they treat. They need to understand that the forces that are productive in treatment are not simply words that are grounded in theory, but feelings and emotions that exist between two human beings, strategies that are innovative, words that are designed to shock the patient into some semblance of reality, that will grow as treatment progresses. We need to understand the logic, the language, the metaphorical expressions, so that we can find decoding methods that will help that person in treatment, understand that this time, treatment is different than what he/she experienced in the past. With the establishment of the therapeutic alliance, the essence of treatment is arrived at and instead of two warring factions, two people opposed to each other, there is a shared belief system which might resemble the I and the thou that Martin Buber so beautifully expresses in his philosophical works.

The next edition will be available in December of this year.

Until we meet again.

Jack Rosberg