In 1957 Karl Menninger wrote “the psychotherapy of schizophrenia is in my opinion, is as much in the mind of the observers as in the mind of the patient. We must change before he can change. He has long been incurable because we have been hopeless.” This was written almost fifty years ago and sadly it still holds true.

I have made many trips to different parts of the world and have found that one of the most important treatment forms has been sorely neglected. The treatment of this condition called schizophrenia is woefully inadequate.

With the advent of the phenothiazines in the early 50’s the world was lead to believe that a medical cure for schizophrenia was imminent. This fiction has persisted in the face of the fact that even the newer medications have not cured anything. This, however, has not made it any easier to train professionals in the use of existing psychological methods which can modify and relieve a patients dysfunctional behavior. However, contrary to the belief of many traditional treators, there are studies that prove without doubt that many individuals with the diagnosis of schizophrenia do recover partially or fully.

However, my interest now, is not to cite these studies but to talk about what I think the process of schizophrenia is and some of the treatment methods that I developed over the years of my experience. So, we have a diagnosis of schizophrenia. The person hears voices, is paranoid, and is delusional, what does this mean? He/she is schizophrenic? What is schizophrenia? Is it a brain disease? Neurobiological condition? A series of symptoms and characteristics? Does the above explain the condition to us so that we can find treatment foci; do we treat the person, or the diagnosis?

In my opinion, the onset of this condition begins with an outbreak of tremendous anxiety and dissolution of identity, which tends to increase the fear; these are terrified human beings. They lose sight of who they are and where they come from. They have annihilation fears and they are lost in a world that they see as life threatening. Something has to happen to this great fear. It’s almost as if these human beings hang between life and death and they retreat to a place and only to a place where the fear and anxiety is processed into symptoms that reduce the tremendous anxiety and schizophrenia becomes a SOMETHING to that person who felt like he/she was nothing and lost. They develop a language and logic that represents survival. The logic they have is their reality. We are faced with a person who feels some relief from fear even though there remains some anxiety and fear that increases or decreases with whatever is seen as being dangerous. Because of this, the world is kept at arms length.

What is treatment? Treatment is not just one thing. It is more than just medication. Medication has a part in the treatment effort. By itself, it only masks symptoms. Psychotherapy is an important part of the treatment. Psychotherapy is an influence process. The first step is to make contact as rapidly as possible in order to prepare the patient for treatment. The initial focus needs to be sustained until the treatment contract is established – otherwise there will be no second step. Once the relationship is established and the patient feels safer – then the alliance – the therapeutic alliance – begins to take shape. However, we must always be aware of the possibility of rupture or break in the alliance, which make it critical for us to repair this broken alliance. We must always be aware of the patient’s role in protecting his/her system of survival and the need to perpetuate this condition. The therapist’s role is to disrupt the psychosis quickly with any means at his/her disposal. (Grotjahn – Sullivan). In the psychotherapy of schizophrenia the method I have developed is called Direct Confrontation which takes into account the importance of making rapid contact with the patient in order to prepare him/her for treatment. The goals of the rapid contact are as follows:

1. To disrupt as quickly as possible the patient’s inefficient interpersonal behaviors.
2. To frustrate the patient’s misplaced efforts to maintain a stable and predictable world.
3. To discourage the patient from relying on inappropriate defensive patterns.
4. To help the patient anticipate increased levels of personal discomfort.
5. To help the patient build more productive interpersonal strategies.
6. To help the patient learn that their experiences can be shared with others so treatment can begin.

What makes a good therapist? Attitude, hope, belief in change, how you feel, and personal involvement, not theories or methods. Let me quote you some ideas that come out of the very distinguished career of Frieda Fromm Reichmann “what is affective in therapy is patient’s experiences in therapy as a helpful and constructive human relationship that reinforces their efforts to come to terms with the troubled past. Not an explanation of how and why they became the kind of people they are.

Strategic psychotherapy is initiated by the therapist. In Direct Confrontation, the use of humor is very important as is being spontaneous and free. The use of language and shock and the power of language and emotions should not be overlooked. Since one of the defensive mechanisms of individuals with schizophrenia is confusion, then the therapist could develop a method of confusion against the confusion. Also, aggression is another defense strategy of the patient, so therapists may develop a way of dealing with aggression by using his/her verbal aggression. One should never forget the important tools of treatment are words and feelings. Also, the importance at arriving at a shared belief system with the understanding that no one is utterly schizophrenic and that fixing on the pathology of the patient is not the only way to do therapy. Every person without exception has healthy parts.

Psychosocial rehabilitation with that individual who has some history of schizophrenia should not be ignored. The importance of retraining and overcoming some of the deficits caused by the condition should be developed on an individual basis with each person. William Anthony, Ph.D. at Boston, University is a superb developer of psychosocial rehabilitation methods, along with Robert Paul Liberman, M.D. at UCLA.

The term chronic schizophrenia is due to the way people are treated by the profession and society. It is an artifact of psychiatric institutions which isolates patients.

Theories are the crutches for the handicapped therapists they help the professional more than the patient. Professionals, psychiatrists and psychologists etc. are poor ambassadors of good will. Implicit in their message to the patients is change. The patient looks at the therapist and thinks, how about you?

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