A clinical diagnosis
of illness is really only helpful when the diagnosis
precipitates treatment that facilitates a recovery
from the illness.
Other than understanding schizophrenia as a broad
psychiatric classification, or a general descriptor
for a pattern of thought and behavioral response I
do not understand what schizophrenia is. Clearly, I
am not alone as it appears that no one really
understands schizophrenia other than the conjured up
interpretations it arouses among psychiatrists and
society. The present consensus among the western
psychiatric profession is the etiology is unknown
and the illness has both a poor prognosis and no
cure.
As I progress I will define my thoughts and my
hypothesis regarding the condition and will describe
a psychotherapeutic social process that has been
applied and has delivered a successful outcome. I
will begin with some postulate assertions:
1) Schizophrenia, and more precisely psychotic
experience, is a primal defensive response to
environmental stimulus.
2) While the response promulgates among all living
organisms it is only Homo sapiens who express any
interest and concern regarding the condition. The
condition is one that appears to be of great
interest to a socially ordered complex intellectual
society. It is of no interest to other living
organisms.
3) The uniquely human fourth dimensional concept of
time is essential in the assignment of any
significance to the condition.
4) Our inimitably human abilities of language
suffusion and disengaged thought allow for the
observation of the condition, speculation regarding
its origin, an interpretation that defines the
condition as problematic and theoretical speculation
and consensus regarding possible etiology and
symptomatic treatment. These same abilities allow
one the opportunity to rationally evaluate a
reaction and to alter the interpretations of
environmental stimuli within the occurring world in
order to gain awareness and control over thought and
behavioral response.
The fundamental objective of treatment is to move
the ineffable response in the presence of
environmental stimuli from the ineffable to one of
effable choice. This only
occurs in the presence of awareness, rational
evaluation of thought and behavior, interpretation
of meaning, and the distinction of choice with
respect to meaning and purpose.
Much of the experience and existence of all living
organisms is unconsciously governed. Homo sapiens
have the unique ability to disengage into a
contemplative awareness of self however this does
not preclude the unconscious governance of many
human systems. Specifically, all of our
physiological functions are unconsciously governed.
We breathe. Our hearts pump blood to deliver
nutrients to our bodies. Our digestive systems break
down food. We defecate and urinate and while we have
some control over these physiological functions and
systems we cannot dismiss their unconscious
requirements out of hand. Similarly, in the presence
of particular environmental stimuli there is a
physiological response. Where we perceive danger our
heart rate increases and an adrenaline response
ensue and where these perceptions persist the
response may evolve to a heightened state of
vigilance and psychotic experience.
Certainly, what we define in a modern, civilized,
and ordered society as psychotic or schizophrenic
today would have been an essential response to
ensure survival of the individual and the species
during prehistoric times in the face of threat and
perceived danger.
Current convention within the psychiatric community
focuses antipsychotic medication as the cornerstone
of treatment for psychotic disorders and
schizophrenia. If the desired societal objective is
to subdue the patient and reduce the threat a
psychotic individual might pose to himself, or to
the broader society, we might argue that
antipsychotic drugs have a place in treatment. They
are however no more effective in resolving the
condition than shackling the affected individual to
a concrete wall. In one case the patient is
physically restrained while in the other he is
chemically restrained. Medication may abate an acute
psychosis however it does nothing to resolve the
interpretations and beliefs that gave rise to the
psychotic response in the first place. If we
consider the risk for abrupt discontinuation of
psychotic drugs and the effectual tardive psychosis
that may result we are ethically compelled to ask
whether a treatment approach of drugs alone without
an attempt to understand what is occurring and to
resolve the underlying issues is anything more than
cavalier and irresponsible.
Human beings have a propensity to seek and assign
meaning to events and to life in general. We define
purpose and meaning and interact with each other and
our environment based on the interpretations we
formulate with respect to our relational existence
with other people, our environment, and the broader
possibilities, life purpose and vocations we pursue.
Our anxieties, our fears, our image of self and of
others all influence how we exist within the
occurring world, how we respond to situational
occurrences, and how we interpret those events in
respect of their uniqueness or generality and what
they mean in terms of our self worth, esteem, and
confidence.
The evolution of Homo sapiens has provided the
species with an evolved and complex intellect that
allows us to rationalize cause and effect in terms
of anticipated results over time. This trait
employing disengaged thought and language brings
forth the notion of judgment. It also brings forward
the concept of values and beliefs in terms of self
and where shared among a group of like minded
individuals the concepts of shared values, common
beliefs and myths, and societal cultural identity.
Our evolution, within this context, has placed
significant value on our individual acceptance and
feelings of safety
and security within predominant societal groups;
family, peers at school or in the workplace, or
other social clusters where identity is established
and common interest is advanced. The evolution of
humanity, not unlike many other organisms, has
evolved toward a cooperative undertaking by a group
of diverse individuals in order to preserve our
collective existence. As a consequence we are
concerned with acceptance, nurturing, involvement,
and reassurance in order to meet this broader
objective.
If, within our formulative experiences, we are left
with the distinction that we are not whole, are not
accepted, are not valued, are abandoned, or are not
secure, that interpretive distinction will cloud and
sensitize our subsequent experiences within the
occurring world. Symbolic environmental stimuli will
carry us unconsciously back to the earlier
experience and will obscure our productive existence
within the occurring world of here and now. As a
consequence only with an enlightenment and awareness
of the influences of past experience on present
thoughts, attitudes, and behaviors, will we succeed
at interrupting the dysfunctional psychopathology
that is perpetuated from the past allowing us to
redefine present experience, interpretation, and
future possibility.
In a nutshell, it is the role of the parent, and in
the parent’s absence the role of the therapist, to
provide guidance and catalyst for this process to
occur. The illustrative model that follows is one
that defines human interaction with self, others,
and the occurring world. In order to perceive a
world of possibility, or possibility in any
situation for that matter, one must distinguish a
relatedness with self, others that one is compelled
to engage with, the situation, and the occurring
world at large. To do so effectively one should be
complete with nonproductive attitudinal and
behavioral interferences that are borne consciously
or unconsciously out of past experience and one
should possess the confidence and security to
navigate the occurring world and overcome obstacles,
large and small, that are manifested through the
course of life.
Where,
in the interpretation of the affected individual the
obstacle, or life itself, is insurmountable the
individual moves to a state of breakdown where
absent rational awareness and intervention he
remains incomplete, unrelated, and does not
distinguish
current and future possibility. The individual is
now positioned as a powerless victim in situational
circumstances, or generally and broadly in life. It
is the role of the therapist to guide the patient in
moving beyond his status as a powerless victim to an
empowered individual willing to accept
responsibility and to navigate life and its
obstacles, therein moving from a state of breakdown
to one of breakthrough where he is complete with the
past and distinguishes relatedness with self and
others and the occurring world. In this state of
readiness possibility is distinguished,
opportunities are refined, and action is taken.
It is obvious then that the therapist’s first task
is to establish a background of relatedness with his
client; one that is trusting, compassionate,
respectful, and caring. Absent this background of
relatedness psychotherapy will not be productive.
Patrick is twenty-two. He was raised in an upper
middle class Canadian family. The family moved
frequently. Patrick has one brother and when he was
nineteen his mother and father separated and
subsequently divorced. He currently resides with his
father and his brother in Toronto, Canada. Patrick
had been diagnosed with schizophrenia. Between
January of 2006 and November of 2008 Patrick
incurred three significant psychotic breaks that
required extensive hospitalization. During one of
these hospital stays during a patient transfer he
managed to jump over a railing falling three stories
and incurred a broken femur and internal injuries
requiring surgery. Patrick has been tasered by the
police no less than twenty times. By late 2007
Patrick’s psychiatrist had prescribed the following
drug regimen in an attempt to control his symptoms:
• Divalproex 1000 mg
• Clonazapam 1 mg
• Seroquel 125 mg
• Citalopram 20 mg
• Haloperidol 5 mg (+ 25 mg IM injection monthly)
• Benztropine 2 mg
• Ativan PRN
All of these drugs were being administered daily and
concurrently.
Patrick was not attending school or work and spent
most of his time, in his heavily drugged state,
watching movies or confined to his bed. He gained
one hundred pounds during 2007 and by the end of
that year was extensively preoccupied with suicidal
fantasy as the only plausible escape from the
horrendous circumstances within which he found
himself confined. Patrick, and his family, were told
that he had a chronic mental illness, of unknown
etiology, that was incurable, and that required a
life long regimen of drugs to reduce the possibility
for psychotic relapse.
Patrick’s father spoke with Patrick’s psychiatrist
expressing concern regarding his suicidal fantasies
late during 2007. The psychiatrist replied that
suicide was a risk and that if Patrick shared his
concern with him that he could reinstitutionalize
him. The father decided that an alternate course of
action was required. He located a paper by Bertram
P. Karon titled “The Tragedy of Schizophrenia
without Psychotherapy” (2001) and was awakened to
the possibility that recovery from the condition was
possible employing psychotherapy and without an
ongoing dependence on antipsychotic medication.
Patrick, with his father’s support withdrew all of
his medication during the subsequent one month
period. Neither he, nor his father, were adequately
aware of the potential tardive effects of rapid
withdrawal of the medication at that time.
Nevertheless, Patrick managed his extensive symptoms
and his father engaged him with a psychotherapist.
He appeared to be progressing well; he reentered
academic studies during the fall of 2008 and was
functioning. After two months at school he relapsed
into a major psychotic break.
So, what went wrong? It is highly probable that the
drugs were withdrawn too rapidly and there were
significant withdrawal effects and tardive
psychosis. Patrick’s earlier psychotherapy was
ineffective. He and his therapist did not establish
a background of relatedness that was sufficient to
undertake the real work required to aid recovery.
Without discounting the value he provides to other
patients the psychotherapist had no experience with
psychosis. I believe the potential for a therapist
to logically entice a patient with a rigid
delusional belief system into a state of normalcy is
highly unlikely. Patrick reported that he
experienced significant symptoms from the time of
discontinuing the medication until his last
psychotic break.
Patrick’s last psychotic break presented the risk
for him and his family to surrender to schizophrenia
as a life long chronic illness. His father’s
determination to provide the opportunity for a
better life for his son, and Patrick’s own
resilience, perseverance, and determination,
translated into their willingness to view the
psychotic experience as an opportunity to learn and
to do better. It is obviously important that they
did not give in.
In her book “Principles of Intensive Psychotherapy”
(1950) Frieda Fromm-Reichmann discusses a
psychotherapeutic process, rather academically and
clinically, to be employed in the treatment of
neurotic and psychotic patients. She focuses
extensively on the conduct of the therapist and the
patient/ therapist interaction. In my opinion she
fails to adequately accentuate the most significant
qualities that allowed her success with patients
categorized as having schizophrenia. Specifically,
she was not afraid of her patients and she
endeavored to stand in the patient’s delusional
world. Fromm-Reichmann described her efforts in
following and accompanying a delusional patient
during his psychotic experience. Reading the book
the critical significance of these qualities appears
inadvertently varnished over.
Jack Rosberg has provided a much more explicit
process map for the psychotherapeutic treatment of
psychotic disorders. Rosberg has illustrated a
Direct Confrontation model for psychotherapy with a
schizophrenically diagnosed patient. He has
summarized five significant steps to the systematic
treatment of schizophrenia as follows:
1. Establishing relationship and trust with the
patient,
2. Facilitating an experience of catharsis,
3. Employing more conventional methods aiding the
patient in his or her psychosocial interferences,
4. Remobilization into society,
5. Aiding in the process of the patient discovering
vocational meaning and purpose in his or her life.
It is obviously significant enough to establish
rapport and trust with a psychotic patient however
as Rosberg suggests the catharsis is fundamental in
resolving a meaningful
path forward. Unless the therapist is willing to
enter the delusional system with the patient, with
sincerity and care, he or she will have little
effect. The therapist cannot hope to have any
success in bringing the patient into a state of
normalcy unless he or she is willing to entertain
entering the delusional system as a full partner
with the patient. The therapist’s ability to meet
the patient’s level of madness with one of his or
her own making that is, in the eyes of the patient,
equally or more absurdly mad than the patient’s own
state is helpful in creating a meaningful background
of relatedness and establishing trust that will
allow for catharsis and the subsequent psychosocial
healing of the patient.
In the height of Patrick’s last psychotic break his
father returned him to a psychiatric hospital where
the attending psychiatrists resumed treatment with
antipsychotic drugs. His hospitalization occurred in
three phases. In his initial phase of
hospitalization he was treated in a short stay
psychiatric unit. A few days following admission his
psychiatrist discharged him in a fully psychotic
state. Within 24 hours his father readmitted him
when he had the delusional belief that their home
was a crack house occupied by vagrants and that he
required admission for drug rehabilitation. The
father successfully drove him in a fully agitated
psychotic state back to the hospital where he was
readmitted. After several additional days he was
again discharged and was doing better although a
couple of days later he took a walk, climbed a
tower, and was seeking rescue. He was talked down by
the police and again readmitted for psychiatric
treatment.
Patrick was discharged with instructions to continue
antipsychotic drug treatment and was referred to a
first psychosis program. He had participated in a
similar program previously and ultimately chose not
to attend. Following discharge I began intensive
psychotherapy with Patrick employing the Rosbergian
Direct Confrontation model for psychotherapy.
Following my enlightenment to Rosberg’s work one day
Patrick and I had just completed a perfectly
rational therapeutic conversation and when I asked
him if there was anything else he wished to discuss
he indicated, somewhat sheepishly, that he wished to
know more about the free mason secret society I
belonged to and wanted to join the society. He had
proposed this several times earlier and I, in
typical logical fashion, dismissed the proposition
as irrational. It occurred to me that this was not
as much Patrick’s request for an invitation into the
free mason secret society, of which I have never
been a member, but rather an invitation into his
delusional world.
I agreed that I would indoctrinate him into the
society and this provided both a venue for the
subsequent ritual of catharsis and a structure for
our psychotherapeutic venue. Under the guise of a
free masonry meeting I indicated to Patrick that the
free masons are expert social integrators and that
in order to develop this level of proficiency that
it was imperative to acknowledge our own madness and
to expel the daemonic forces that existed within us.
With his willingness to proceed I indicated to him
that we would now exorcise the evil that existed
within him. He expressed reluctance at doing so
indicating that he would not be able to control
himself and that he was apt to break the floor
because he was so angry and there was so much evil
within him. With some additional encouragement he
screamed until it was all expelled and his throat
was sore and then I ordered him to scream some more
and then to get onto the floor and kill it, which he
did. He stomped and pounded his fists on the floor
killing it until his hand was sore, following which
I told him to get rid of it all, flushing it down
the toilet. I then got on my hands and knees with
him and helped him search to ensure there was no
evil residue remaining.
When he advised me the last bit was there but
already dead and only required disposing of I
scooped it up, sent it down the drain and ordered it
to never return.
Following this initial catharsis he indicated that
the evil was now all gone, he was visibly pleased,
smiling, but expressed some anxiety suggesting that
he now had to learn to live without it. The
following day he confirmed that he had succeeded at
expelling the evil and that he would now have to
reluctantly face the world without it. He indicated
that he had frightened himself when he had gone to
the bathroom and thought that the evil had
resurfaced in the toilet however he acknowledged
that it was not there.
Several weeks later he promoted that another
expulsion was required. The second catharsis was
remarkably like the first however the symbolic
ritual was focused in this instance on exorcising
his fears and misconceptions regarding the police
and psychiatric services. Given his past experiences
one would easily forgive his paranoia and concern
regarding these authorities.
When an individual possesses a rigid delusional
belief that he is overtaken by some daemonic force,
although perhaps unconventional, the obvious thing
to do is to aid that person in exorcising the
daemonic force through a symbolic ritual of
catharsis. With this interference out of the way
more conventional approaches to psychotherapy can be
undertaken.
Central to Patrick’s earlier symptoms were recurring
delusional and paranoid beliefs that others were
battling him for control and dominance. He has begun
to distinguish that this is merely a story contrived
in his own mind and that it is his automatic already
always listening because he has been distrustful of
other people. As psychotherapy progressed Patrick
recounted experiences during his formative years,
particularly with his peers at school, where he felt
ostracized, devalued, and that shaped his confidence
in interacting with others and his distinctions that
he could not relate to others, self, and the
occurring world. The breakdown of his parent’s
marriage and a physical altercation he had with his
father during that time left him with the
distinction that he was responsible for the marital
breakdown. The actual events that transpired may not
be significant to someone else. A judgment from the
outside might suggest they were irrational. It is
important that these events and others were
significant to him. With other patients content may
differ however process is similar.
It is nothing short of remarkable that Patrick’s
PANSS score decreased from 137 to 58 during the
course of one month while engaged in once to twice
daily sessions of psychotherapy with a duration
between thirty minutes and three hours per session.
Concurrently his antipsychotic medication was
reduced from 6 mg of Respiridone and 25 mg of
Seroquel to 4.5 mg Respiridone and no Seroquel.
Following an additional month of treatment with
psychotherapy the PANSS was observed at 37 and the
Respirdone was concurrently withdrawn to 1.0 mg, and
over the course of one additional month the balance
was withdrawn and Patrick was experiencing no
symptoms. While psychotherapy continues its
frequency has also decreased to two sessions per
month. Seven months later Patrick reports no
symptoms, is not taking any medication, has secured
summer employment and has been working regularly,
and has taken the steps to return to academic
studies in September. He has formed some friendships
and is presently cautiously optimistic about the
future gaining additional confidence as time lapses
with the desired results.
These are Patrick’s accomplishments. They are not
mine. I suggest it is imperative that the therapist
acknowledge the achievement as the patient’s. The
objective is to have the patient accept
responsibility and to have the patient distinguish
his ability to navigate the occurring world and
overcome life’s obstacles. An objective of any
psychotherapeutic relationship is the ultimate
ability of the patient to become self-sufficient in
his relatedness with self, others, and the occurring
world. An ongoing dependency on the therapist or the
process of psychotherapy is not productive. The
therapist should be aware of his own egotistic and
narcissistic tendencies and avoid the desire to
credit himself for the patient’s achievements. The
patient’s ability to recover and to remain well is
proportional to his ability to understand that he is
responsible and that he is cause in the pursuit of
meaning and purpose in life and effectively
resolving the encumbrances that arise through the
course of navigating life.
Mental illness can only exist in the context of the
patient’s past. It is the past experiences that have
shaped the individual’s interpretations of his or
her interactions, social dynamics, and the occurring
world. Absent the past the individual is not ill. To
resolve the condition one needs to resolve the
effects of conscious and unconscious present
interpretations that permeate from the past.
Schizophrenia, like other mental illnesses is one
whose origins pervade from the psychosocial
interpretations and interactions that become the
collective experience of the individual. The
condition is a primordial, and in modern society
labeled a delusional, system of defense. Promoting
that biological and chemical intervention alone will
resolve the condition is not merely misguided it is
irresponsible. The patient is expected to live his
or her life both on top of the underlying condition
and in conjunction with the significant and serious
side effects that arise as a consequence of the
medication. Conventional wisdom that discourages
psychoanalysis in favor of promoting that the
patient needs to get on with his or her life without
ever resolving the fundamental underlying issues is
ineffective and irresponsible.
We can take some solace in the understanding
provided by Courtenay Harding (The Vermont
Longitudinal Research Project) that observes there
is a resilient quality to the human condition and
that over time, despite their limiting beliefs, and
traumatic life experiences, people recover. The
process of psychotherapy can be an integral and
fascinating catalyst in facilitating this recovery.
References:
Breggin, P., “Medication Madness”, (2008)
Fromm-Reichmann, F., “Principles of Intensive
Psychotherapy”, (1950)
Harding, C., “Changes in Schizophrenia Over
Time”, (2003)
Jaques, E., “The Life and Behavior of Living
Organisms”, (2002)
Karon, B.P., “The Tragedy of Schizophrenia
without Psychotherapy”, (2003)
Rosberg, J. “A History of Treatment and
Current Ideas”, (2007)
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