The Use of Direct Confrontation 

Establishing human contact with the patient is the sine qua non for the delivery of any behaviorally-oriented treatment of the schizophrenic (including psychotherapy). However, creating a relationship that will lead to effective psychotherapeutic interventions for treating schizophrenia continues to be difficult for most therapists (Lamb, 1981; Lidz & Lidz, 1988; McGlashan, 1983; Scheflen, 1961; Will, 1975). This difficult challenge occurs largely because schizophrenia produces bizarre and unpredictable patterns of behavior in the patient. The typical schizophrenic patient can be obnoxious, treatment-resistant and hostile to the therapist; it is no surprise that many therapists perceive schizophrenic patients as dangerous. This behavioral profile also interferes with "normal" social communications by inhibiting and distorting the expression of common social conventions used to initiate and maintain human relationships.

Individuals diagnosed as schizophrenic quickly discover that their sense of personal efficacy has been overruled by the demands and symptoms of the illness. Despite their best efforts to apply their intellectual and emotional resources, they experience an exquisite sense of helplessness. Their illness forces them adapt to the inevitable perceptual distortions and intellectual confusion that accompany schizophrenia. The patient's uniqueness as a person manifests itself only in the variety of behaviors used in his or her efforts to compensate for the overwhelming demands of the illness.

As the illness progresses, the patient has no choice but to adapt to the illness-dominated, socially alienating behaviors. Over time, the patient comes to view the occurrence of those bizarre behaviors as expected, predictable and stable parts of his personal and social world. The patient's use of these behaviors is likely to be further reinforced as he learns that using them can drive away perceived threats to personal stability. By this point, the behaviors have evolved into a truly important component of the patient's social repertoire, with the maintenance and evolution of the behaviors being shaped more by the patient's now maladaptive interpersonal needs than by the illness itself.

It is fair to say that such obstacles to treatment are beyond the experience of most therapists. Few therapists have the requisite training in the techniques necessary for effective intervention. Unfortunately, this lack of training in psychotherapeutic techniques is not confined solely to the treatment of schizophrenia. The contributions of family systems, epidemiology and developmental theory to our knowledge of practical treatment applications have been all but abandoned as training institutions increasingly focus on identifying biological "solutions" (Lewis, 1991).

Lamb (1981) argues that the therapist should support the patient's efforts to productively adapt to the symptoms of his illness:

....the treatment of the schizophrenic patient should emphasize working... to expand the remaining well part of the person and thus his functioning rather than to remove or cure psychopathology; the focus should be on the healthy part of the personality, the strengths of the person. (p.67)

Inherent in this argument is the obvious notion that the therapy situation can provide a setting within which the patient is able to adapt more effectively to the demands of the illness than if he were left to his own devices. Malm (1988) in a recent contribution on treatment resistance in schizophrenia, suggests that treatment should not focus on restoring patients to their pre-morbid condition; instead, the objective should be to foster whatever change is possible given the resources of patient and therapist. The arguments of both Lamb and Malm imply that partial recovery can be and should be, a reasonable treatment objective.

At the same time, however, it is clear that in the real world of today's treatment programs many, if not most, schizophrenic patients are not receiving the types of treatment that would move them toward this objective. In fact, the kind of treatment they are receiving may be perpetuating rather than alleviating the schizophrenic condition. Many therapists fall victim to feelings of helplessness as they stare into the face of schizophrenia. These feelings may be what Harry Stack Sullivan (1962) had in mind when he observed that many therapists totally fail to become involved in the lives of their schizophrenic patients.

This perceived helplessness certainly makes it much more difficult for us to remember that effective treatment must be based on the creation of a sense of relatedness with our patients--even if those patients happen to be schizophrenic (Lidz, 1969). If we are to effectively approach the schizophrenic patient, we have to place ourselves, as caring therapists, "in the spirit and with the expression of simply meaningful spontaneity and frankness" (Fromm-Reichmann, 1952).

Making Contact with the Patient as Precursor to Treatment

The importance of disturbing the schizophrenic process in order to facilitate a treatment relationship has never been questioned (Malone, 1961). The problem for the clinician has always been how to establish such a relationship at the core of effective treatment, while simultaneously avoiding a situation in which the treatment itself becomes interminable and economically unrealistic (Talbott, 1981). Despite the significance of this treatment issue, there has been little written in the literature that provides clear direction for psychotherapists who seek to reach out and help these patients re-establish productive and meaningful human contact.

Lidz and Lidz (1988) make the important point that relatedness with the patient should be established as a precursor to treatment; it is in the context of this relationship that the patient "can examine his life together with the therapist and begin to assume responsibility for himself" (p. 52). They point out that schizophrenic individuals are neither insensitive nor unaware of the significance other people have in their lives. This awareness exists despite the stigma they generally attach to their interpersonal relationships:

...the schizophrenic patient is ever alert to pretense, which may include the therapist's hiding behind a prescribed role. He will usually respond only to a real person who is interested in him as an individual, an individual who is confronted by problems that seem insurmountable. (p. 48)
Brody (1952), in an important early contribution, described the initial steps in therapy as the "establishment of contact." He cited the pioneering work of Schwing, Federn and Rosen and credits Grotjahn as among the first to recognize the need to make contact with the psychotic patient by any means possible.

Although clinicians have long recognized the need to make contact with their schizophrenic patients, few have seen it as representing a truly essential skill for effective psychotherapy. Fewer still have understood that the techniques required to establish a sense of relatedness between patient and therapist are quite different from those used in more traditional therapeutic interactions (e.g., techniques related to the development of transference):

...Far less consensus exists in the literature about the techniques required to establish relatedness. Some strategies appear to be generally held; others depend on the particular patient. Most writers agree that consistency and straight forwardness are important at this stage of work, but that classically analytic strategies of passive neutrality and anonymity are not. (McGlashan, 1982, p. 914)

In exploring innovative methods for making contact with the schizophrenic patient, the insights of John Rosen (1952) continue to be highly relevant. The pathbreaking nature of Rosen's work was recognized by Temple University's Department of Psychiatry when it set up an institute to study, in situ, the theoretical and clinical insights of Rosen. Their careful and well documented analysis of Rosen's techniques remains unique in the literature.

Rosen was able to make contact with schizophrenic patients much more quickly than many had thought possible:

“Rosen often established rapport in the early minutes of a first interview even with very evasive or withdrawn patients. We have repeatedly seen him succeed with patients who had not responded to other therapists over a period of days and a week. This ability to establish a relationship with a new patient was the most impressive of (his) skills. He appeared to accomplish this with a combination of a confident, assertive, "talking (sic) over" attitude, a friendly and understanding manner by promising and rendering service by gaining the patient's attention to him and by direct interpretation or confrontation”. (Scheflen, 1961, pp. 68-69).

Fromm-Reichman (1952) and Eissler (1952) both felt that Rosen's personal style, his tone of voice, attitude, intentness of speech and convincing speech, was more important than his specific cognitive interpretations. In fact, even though Rosen's theoretical approaches to the treatment of schizophrenia have not proven to be uniformly effective, his clinical skill in making contact with his patients through his ability to disrupt their psychosis continue to challenge and stimulate those therapists familiar with his work: "If (Rosen's work) did no more than to shake us out of our complacency and even if it never cured anyone, it would be nonetheless invaluable" (Kubie, 1961, p. xxii ).

Making Contact to Create Relatedness

An extensive review of the literature provides no guidance as to how Rosen's techniques for establishing contact can be used to bring about the sense of relatedness described by Lidz. However, in our own work, we have intuitively focused on the necessity of making human contact as the basic platform from which other treatment strategies consistent with the patient's needs can be developed. Our work has shown that the basic platform can be constructed most quickly and effectively by focusing specifically on the contact process.

Making contact in conceptualized as a vehicle for accomplishing certain specific and preliminary objectives. Based on our extensive experience, we've created the following treatment objectives as guidelines for our work with schizophrenic patients. These guidelines should be seen as an overarching framework to which specific, contact-oriented interventions can be attached:

1. To quickly disrupt the patient's illness-directed and counterproductive 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 will necessarily 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 or her experiences with others, thus establishing the cornerstone of effective treatment.
 

Clinical Assumptions

The initial contact with the schizophrenic patient is often filled with the same sorts of social amenities one might engage in when meeting any other person for the first time in a nonclinical setting. Just as you should not enter a new relationship of any sort with preconceived ideas about other individuals, you should not allow rigid assumptions about the patient to contaminate the first therapeutic encounter with the schizophrenic patient. You are making contact with a human being and there is no reason to approach the relationship expecting the other person to yield to you. You are not omnipotent. It is patently unfair for the therapist to enter the relationship with this orientation.

One must also believe that the patient has the desire and ability to share his or her* experiences with the therapist. This is not as difficult as it sound. We have observed that patients who initially appeared incapable of talking about anything whatsoever have often changed dramatically. Attracted by our persistent and provocative interest, they have eventually opened up with sometimes amazing insights about their unique human condition. These methods must be systematically applied, especially in working with those patients who exhibit the disarming, inappropriate and personally frightening aspects of the schizophrenic experience (i.e., active hallucinations, well-organized delusional systems, strong paranoid logic).

Any worthwhile relationship is a product of compromise and the therapist must therefore be willing to make certain compromises. However, one thing which cannot be compromised is the need for the patient to speak in an understandable language. Without a common language there can be no communication; and without that communication there can be no meaningful process of sharing and compromise leading to a productive therapeutic relationship (Rosberg & Stunden, 1989).

The therapist must be prepared to talk a great deal, using speech to convey feelings rather than ideas. The therapist must have ready access to his own feelings about who he is and what he is doing with the patient. However --and this is crucial--the therapist’s responses must be based on the patient’s level of social appropriateness. If the patient is rude and unresponsive, the therapist must immediately communicate to the patient that such behavior is not acceptable.

For example, if the patient turns away from the therapist's effort to initiate interaction, it is perfectly acceptable for the therapist to convey her annoyance to the patient. The therapist cannot help the unresponsive patient. You can demand the patient's attention and refuse to accept her efforts to ignore you. You can and should insist that the schizophrenic patient behave in a manner consistent with normal social intercourse.

The therapist must make the patient aware that help is available in the here and now. The patient must realize that the therapist does not just exist in the same time and place. Instead, the patient should recognize the therapist as a helping agent who fosters and encourages an active process of change. At other times, the therapist may clarify her own appreciation of the patient's experience. In some cases, it may be possible to make comments which accurately reflect the patient's unverbalized feelings. Such actions taken by the therapist encourage the patient to feel comfortable and accept the risk they take in allowing the therapist to make contact.

Thus, the therapist's first steps at making contact should be designed to help the patient respond to the therapist in a socially appropriate way. When the patient makes progress in this direction, the therapist must be a good listener and observer, conveying genuine interest and regard for the patient in anticipation of a genuine therapeutic dyad. Simultaneously, the therapist must utilize her understanding of the patient's fears, anxiety, defenses, tactics and logic system to keep the patient involved in the process. If the patient stops reacting to this embryonic relationship, it is because the therapist allowed it is to happen. Communication, even if one-sided, must continue; a silent therapist is of no value until the patient is ready to tell her story.

Specific Interventions

Following are some interventions which you, as a therapist, may find useful in working with schizophrenic patients.

Helping the Patient Talk.
First, you need to place priority on getting the patient to interact verbally. While nonverbal communications are important, you cannot develop a therapeutic relationship based only on nods, gestures, or grunts. You must help the patient reach a place where she can tell her story. At some level, every patient wants to tell someone, anyone, what her life has been like. Yet many schizophrenic patients are so uncomfortable in the therapy setting that they cannot begin to open up. Others will only want to find out if they can titillate or arouse the therapist's voyeuristic needs. Nevertheless, you should help the patient feel that what she is saying is being understood, which can be accomplished by accepting the reality of the patient's experience as she tells her life story.

A key indicator of probable success is the patient's ability to make eye contact. Patient who maintain eye contact usually want to talk; this does not, however, mean that they are comfortable. They may be angry with you for threatening their long established defenses and the eye contact may be intended to scare you off. Yet even this interaction provides you with an opportunity for interaction, in that the patient has shown through body language that she wants something from you. When the patient lets you know, however subtly, that you may be able to do something for her, no matter how alien, remote, or bazarrely formulated, you've made an important first step toward making contact.

After the patient begins to talk, you should increase the tension in the relationship by raising the issue of the patient's desire to get better. You need to ascertain whether the patient truly wants help. Further, if it seems that she wants help, you need to address two questions: What type of help does she want? And is she willing to make a contract with you to meet specific objectives? The patient must convey this information in some overt way so that the reality of their behavior binds her to the developing relationship.

We must always remember that psychotherapy does not begin when the patient and therapist begin to talk with each other. Each may be presenting attitudes that have no therapeutic purpose. However, the time they spend together must prepare the patient for the treatment that is to come. For example, when we encourage the patient to acknowledge dysfunctional behavior we make inroads into the self concept that can contribute to future therapeutic change. Further, when we persuade the patient to accept us into her life, the relatedness and emotional involvement that are precursors to psychotherapy become a reality.

Developing a Trusting Relationship.
Of all the elements involved in our approach to making contact, the most important is the creation of a sense of trust between therapist and patient. Patients must feel safe with the therapist and believe that the therapist is strong enough to protect them from the illusory but threatening aspects of their illness. Patients must learn that the therapist provides a sanctuary for their illness and that the therapist will never do anything to harm or violate them.

The patient must openly acknowledge and confirm the fact that she feels safe. If necessary, the therapist must force this issue into the open and insist that the patient share any hidden concerns about safety. This process is centrally important for several reasons. It introduces the concept that trust can be established and maintained on a verbal level. It also reinforces a fundamental aspect of all human relationships; that words between two people can symbolize their mutual obligations and responsibilities in the context of the relationship.

Helping the Patient Share the Experience.
Even after making verbal contact, however, you're still faced with the problem of how to share in the patient's awareness of her own experience. We've learned from our clinical experience that you can learn more about the patient's subjective world by surprising her with the unexpected. This event/surprise must be genuinely unexpected and totally unforeseen. It should truly startle the patient into a reaction that acknowledges the presence of the therapist and to which the therapist can respond. It may be amusing or stern, loud or soft, angry or sad, harsh or gentle. It can arise from a context that is unanticipated or even incongruous. Yet--and this is the key--it must make the patient stop to consider what has just happened. It must make the reality of the therapist's process part of the patient's illness-controled world.

Disrupting the patient in this way may also be disturbing to her illness-based psychological stability. That is, the patient may experience the disruption as a challenge to the integrity of the defenses she has build up. The therapist must be prepared to deal with a wide range of potentially intense feelings; in doing so, you should always remember that this experience of having her confidence shaken can be quite terrifying for the patient. Over time, however, this intervention can help quiet the patient's resistance to the contact process by focusing both patient and therapist on the fact that constructive human interaction is possible and desirable.

Making the Patient Feel Worthwhile.
It's all too easy to take the schizophrenic patient for granted and to forget that everyone needs to feel appreciated for the good that is within them. It is important in any human relationship to make the other individual feel special and worthwhile. As a therapist, you may want to draw attention to the patient's genuine assets; examples would include intellectual resources and interests, sensitivity to others, or strength in the face of the illness. Sometimes an appeal to the patient's exhibitionistic qualities is in order. This may be particularly valuable when the therapist finds something uniquely attractive in the patient.

Avoiding Therapeutic Neutrality.
The therapist who makes a schizophrenic patient feel special and valued can never be truly objective. Every therapist must recognize that he or she does have attitudes about and feelings toward their patients. Patients are not neutral objects with no valence and the therapist cannot afford to give them the impression that they are. The desirable option is to acknowledge your feelings toward the patient, and explore those feelings to better understand your patients' stimulus value as human beings.

This advice, of course, is contrary to some schools of psychotherapy which treat therapist neutrality as a central tenet of psychotherapy; the justification is related to the need to avoid countertransference problems. We must remember, however, that making contact with a schizophrenic patient is not a countertransference issue. The patient has a need to be stimulated by the therapist's own strong feelings, in much the same way that the child needs her parent to stimulate, encourage and provide structure.

Thus, the therapist may occasionally have to structure the patient's response in order to make the patient accessible to a vigorous therapeutic thrust. Or, alternatively, the therapist's encouragement may be tender and gentle. In either case, the goal is the same: to make the patient feel that there is someone in their life who genuinely cares about them.

Taking Charge of the Patient's Life.
If contact is going to occur, the therapist must become established as the dominant force in the patient's life. It is this energy that allows the therapist to gain mastery over the patient's reactions to the illness. Only then does the patient understand that the illness has prevented her from directing her life in productive ways. Over a period of time, the patient learns how her previous efforts to adapt to her illness-dominated world were at best inadequate and at worst disastrous. For the first time, the patient may realize that there is a realistic prospect for getting well.

This responsibility, that of controlling others' lives, should not and cannot be taken lightly. Therapists who seek to establish this degree of control over their patients lives must have control of themselves. They must feel confident in their ability to help the patients and comfortable with themselves as human beings.

You cannot direct treatment successfully if you wait for patient approval of the interventions. Whatever happens, you must take charge, whether or not that meets with your patient's approval. You must not yield to the patient's inevitable defensive maneuvers. If you allow the patient to control the growth of the relationship or the course of the therapy, real progress cannot be made (Rosberg & Stunden, 1989).

Rejecting the Patient's Illness.
If the patient is to relate successfully to the therapist, both must understand that the patient has personal qualities that remain uncontaminated by the illness. The therapist must not become so preoccupied with pathology that the positive characteristics of the patient are forgotten. The therapist can sometimes impart this by rejecting the illness and isolating it from the patient. For example, the therapist can become angry at the illness but convey feelings of concern for the patient. Telling the patient that her illness has made her an unpleasant human being may also be appropriate. Note, however, that this would only be verbalized if the converse were true, i.e., that without the illness she would be a more pleasant human being.

The therapist must always be careful not to add to the patient's inappropriate guilt about being sick. Patients often feel responsible for their illness and helpless to do anything about it. You, as the caring therapist, should help the patient understand that she is not to blame for what has happened to her. You should never forget that patients do not seek to become schizophrenic.

Thus, the patient and therapist must not get bogged down in the apparent limitations imposed by the illness. The therapist works with what is there and should not let the illness get in the way. It is important to look ahead and not look back. This tactic reminds both patient and therapist that there is indeed hope and that the illness does not necessarily have to continue to control all aspects of the patient's life.

Treating the Patient With Respect.
It is vital to respect the humanity of the patient at all phases, even during direct efforts to make contact and gain control. One must not take the patient for granted nor deprive her of her dignity through excessive or arbitrary use of authority. Patients should always be given choices, reflecting the therapist's confidence in her ability to know and do the right thing. This action by the therapist communicates both a belief in her ability to improve and a positive regard for her as a human being.

The ability to make decisions, even about seemingly unimportant matters, enhances the patient's self-esteem and heightens her belief in the strength and basic honesty of the therapist. By consistently treating the patient with respect, the therapist can convince her that the primary objective of therapy is really the patient's well-being.

As these interactions become increasingly successful, however, the patient may begin to agree with whatever is said to her. The contact process can become virtually hypnotic, with patient and therapist locked into a distinct world directed by the therapist for the patient's benefit. When this situation develops, you will want to allow the patient as much cognitive control as she can handle. During therapy, you may want to preface certain interpretations with the caveat that they may be wrong; encourage the patient to give feedback, especially if she feels that something is not quite right. Prompting the patient to not let you put words in her mouth may also be quite helpful.

The Role of the Therapist

One of the primary tasks of the therapist is to stimulate the curiosity of the patient. The therapist must become intriguing enough to the patient that she will want to pursue the relationship. To put this in context, it is important to remember that the schizophrenic patient lives in a forbidding world of unwanted rules and restrictions and is conditioned by society and by the treatment process itself to the norms of confinement and control. To often, these experiences have deprived them of any sense of individuality; schizophrenic patients have essentially lost their right to express their feelings about the world around them. They've come to believe that everything they do is contaminated by their illness. They internalize the message that society expects them to be sick.

However, there is a positive and constructive alternative. What if the therapist is comfortable with the patient's feelings? What if the therapist communicates this comfort to the patient, stimulating her and encouraging her to re-emerge? Might she then become interested, with her intense curiosity leading her to take halting steps toward making contact? In this framework, making contact symbolizes an opportunity for the therapist to engage in controlled abandonment. Perhaps most fundamentally, the therapist commits to do whatever is necessary to reach the patient.

Making Contact, Psychotherapy and the Future of Treating Schizophrenia

The practical problems associated with treating the patient whose illness mandates a retreat from human contact overwhelm many therapists. The issues and problems involved are totally foreign to their clinical training and experience and they may just not feel ready or able to proceed with therapeutic interventions. The ready availability and effectiveness of neuroleptic medications permits the therapist to withdraw from the patient at the most difficult phase of the illness. As a consequence, further attempts to make contact and initiate psychotherapy may be postponed until the patient is seen as willing or able to accept it (Rosberg & Stunden, 1990). This approach assumes that human contact can be of little benefit to someone who has become isolated by the rigors of the illness. The therapist, by internalizing this assumption, may continue to avoid contact altogether. Brody's admonition to the therapist to make contact through any means possible goes by the wayside.

We feel that the approach described here, centrally involving the active "reaching out" to the schizophrenic patient, provides a constructive and effective alternative to avoidance. The techniques do not require the therapist to give up the use of medications if that is helpful in accessing the patient. We also recognize that the demands of the illness may in some cases prevent the patient from accepting the therapist's offer to make contact. However, the responsibility for assessing the situation lies in the hands of the therapist, who must always remain accountable for fostering a sense of relatedness with the patient. The therapist should consistently seek to nurture a meaningful relationship with the patient, a relationship which will, over time, permit other kinds of treatment-oriented contact to take place.

This approach provides a method for creating a meaningful history which can provide the foundation for a human relationship. The sharing of time and experience creates a history unique to the evolving process between therapist and patient. How often have we stood with someone in an elevator, going from floor to floor, with any potential relationship remaining only nascent? What if one passenger imposes in some way on another, perhaps asking the time or for directions? While the seeds of relatedness will begin to stir, they will not take root. The interaction requires nothing more than a casual and impersonal reply. Yet, if the elevator get stuck between floors, a relationship centered on the shared history quickly develops among the elevator's passengers.

Therapist and patient too often ride silently from floor to floor, only dimly aware of one another, each hoping to be ignored until the other reaches his floor and walks out the door. Casual thoughts might be shared, perhaps even with some purpose beyond an impersonal exchange of information. But what if they do not understand each other? What is one becomes upset? What it one attacks the other? How will they react, who will try to deal with it? If both therapist and patient simply get off the elevator and ignore their mutual journey the history they created will have gone for naught.

The contact process invites the therapist to enter the patient's life with a hopefulness quite different from the patient's previous experience. The patient is not likely to get better if the therapist lacks hope. As therapists, we make a powerful statement about our feelings of self worth when we treat patients who themselves believe they are hopeless. When we share our hope with such patients we encourage them to believe in human values that foster growth and self-fulfillment. The therapist's positive attitude and tactics can help the patient move from a position that denies the worth of human relationships to one permitting relationships to be examined for what they are.

When we try to make contact with out patients we must also remember that schizophrenia is seldom a matter of life and death. Schizophrenia is not an acute "battlefield" type wound requiring immediate, drastic intervention; is not a medical triage situation. The patient who is not yet ready for treatment may still eventually benefit from making human contact. Even though people with schizophrenia seldom die of the disorder, their lives are significantly diminished if human contact is denied them. To abandon them to their illness is to deny their humanity.

If psychotherapy of any type is to succeed, both patient and therapist must believe that a sense of relatedness between them can indeed be formulated. If nothing else, this belief persuades both parties that the patient is not beyond reach. Neither therapist nor patient can afford to wait. It doesn't matter whether the clinician views the patient as sick biologically or well defended psychologically. In successful treatment, theory is seldom as important as practice.

This is the core of the issue. Treatment must be approached with a focus on the human being with the illness. Successful treatment is more dependent on the patient-therapist relationship than on the application of any particular treatment technique. While we know that a relationship can never be substitute for treatment, we also know that without such a relationship treatment itself cannot exist.

*The pronouns 'his' and 'her' are used to refer to any schizophrenic patient of either gender. For convenience, we will refer primarily to 'her' as a generic usage.

References:

Brody, E.B. (1952). The Treatment of Schizophrenia: A review. In E.B. Brody & F.C. Redlich (Eds.), Psychotherapy With Schizophrenics. New York: International Universities Press.

Eissler, K.R. (1952). Remarks on the analysis of Schizophrenia. In E.B. Brody & F.D. Redlich (Eds.), Psychotherapy with Schizophrenics. New York: International Universities Press.

Fromm-Reichmann, F. (1952). Some Aspects of Psychoanalytic Psychotherapy with Schizophrenics. In E.B. Brody & F.D. Redlich (Eds.), Psychotherapy with Schizophrenics New York: International Universities Press.

Kubie, L.S. (1961). Preface. In A.E. Scheflen (Ed.), A Psychotherapy of Schizophrenia: Direct Analysis. Springfield, IL: Charles C. Thomas.

Lamb, H.R. (1981). Individual Psychotherapy. In J.A. Talbott (Ed.), The Chronic Mentally Ill: Treatment, Programs, Systems. New York: Human Sciences Press.

Lewis, J.M. (1991). Swimming Upstream: Teaching and Learning Psychotherapy in a Biological Era. New York: Brunner/Mazel.

Lidz, R.W. (1969). The Influence of Family Studies on the Treatment of Schizophrenia. Psychiatry, 32, 237-251.

Lidz, R.W., & Lidz, T. (1988). Some Comments on the Supervision of the Psychotherapy of Schizophrenic Patients. Proceedings of the V International Symposium on the Psychotherapy of Schizophrenia (45-61).

Malone, T.P. (1961). An Operational Definition of Schizophrenia. In J. G. Dawson, H.K. Stone, & N.P. Dellis (Eds.). Psychotherapy with Schizophrenics: A Reappraisal. Baton Rouge, LA: Louisiana State University Press.

Malm, U. (1988). Good Routine Treatment in Schizophrenia. In Treatment Resistance in Schizophrenia. Braunschweig/Wiesbaden: Vreweg.

McGlashan, T.H. (1983). Intensive Individual Psychotherapy of Schizophrenia: A Review of Techniques. Archives of General Psychiatry, 40, 909-920.

Rosberg, J., Stunden, A.A. (1989). The Principles of Direct Confrontation: Psychotherapy with the Schizophrenic Patient. Nordisk Psychiatrisk Tidsskrift, 43, 491-498

Rosberg, J., & Stunden, A.A. (1990). The Use of Direct Confrontation: The Treatment Resistant Schizophrenic Patient. Acta Psychiatrica Scandinavica, 81, 352-358.

Rosen, J.N. (1953). Direct Analysis: Selected Papers. New York: Grune & Stratton.

Scheflen, A.E. (1961). A Psychotherapy of Schizophrenia: Direct Analysis. Springfield, IL: Charles C. Thomas.

Sullivan, H.S. (1962). Schizophrenia as a Human Process. New York: Norton.

Talbott, J.A. (1981). The Chronic Mentally Ill: Treatment, Programs Systems. New York: Human Sciences Press.

Will, O.A. (1975). The Conditions of Being Therapeutic. In J. G. Funderson & L.R. Mosher (Eds.), Psychotherapy of Schizophrenia. New York: Jason Aronson.

Back to Top