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Some
Notes on Schizophrenia and the Strategic
Psychotherapy of Direct Confrontation.
Schizophrenia is a condition that develops over a
period of time. This condition may have an organic
base but environmental conditions need to exist for
the illness to eventually erupt, surface and become
a single reality in that persons' life. The
beginnings develop early and grows usually without
it being perceived by the patient and/or her family.
There are indications of some disturbances in that
person, however, the problems and developing
conflicts are difficult to isolate, not only by
those around the patient, but even by the
professional psychotherapist or psychiatrist.
Schizophrenia is very poorly defined in the
literature even though Morel, Kraeplain, Bleuler,
Schneider and Langfeldt have classified and
reclassified the symptoms and characteristics of
schizophrenia, as has the DSM codes of the American
Psychiatric Association. The symptoms and
characteristics do not explain this human process,
which has been defined more accurately as a syndrome
or many related disorders that could be caused by a
multitude of factors. It is vital that this
condition is clarified in terms that suggests a
sense of logic that demystifies the condition and
allows all of us a better understanding of these
individuals not only for treatment purposes, but for
the sake of their humanity.
I will suggest a simple definition that might
clarify the issues of schizophrenia after its
apparent early onset. It should be understood that
even though it seems to surface suddenly, that it
has been growing in that person for years. So to
repeat, the onset is not a quick reaction, but is
preceded by a pre-morbid condition that is
indicative of this serious mental disharmony. The
beginning phase is one filled with terror. These are
terrified human beings and that great fear leads to
a disintegration and dissolution of that persons
identity. She doesn't know who she is or where she
comes from. She has annihilation fantasies and fears
destruction. This enormous fear drives the person
backwards until she can develop around her a system
of defenses. The fear is processed by the person
into a number of symptoms, such as delusions,
hallucinations and paranoia. There are those who
believe that this represents the organisms attempt
to cure itself. It does serve to reduce that great
fear and out of this comes a new identity with its
own logic and language, that we call schizophrenia.
This system of life is to that person a survival
mechanism that becomes resistant to change, because
it represents life to that person. With these
thoughts in mind, it is imperative that we
understand that the patient may see herself as being
well and often denies that she is sick or needs
help. How can we contact that human being in such a
way that she will allow us into her life and the
bond between psychotherapist and patient will grow
strong enough to begin the process of recovery.
I will attempt to explain a psychotherapeutic method
that points out one of the roads that we can take in
sharing with the patient, the agony of her
existence. However, we must make an honest
evaluation of treatment and with an open mind allow
ourselves to acknowledge our failures so we can
create more effective treatment methods.
Traditional psychotherapy and other treatment
modalities have not succeeded well enough with
patients who are diagnosed as schizophrenic, because
their approach has been focused on the patient
gaining insight and dealing with intrapsychic
conflicts. With the long term schizophrenic patient,
we have found that in many cases, these patients
cannot process insights well enough to effect
behavioral changes. We are proposing a treatment,
that is not a priori, but a result of many years of
experience and that has as its first step the
establishment of relatedness. If we do not succeed
in this first step, treatment cannot go beyond the
initial stage. Our active and direct treatment
methods have a design that depends on this first
step. It focuses on the present dysfunctional
behaviors of the patient, so that reality has a
stronger part in the life of the patient. We believe
that an emphasis on problem solving and reality
based goals lead to achievements that are ego
building and tend to reduce delusional conflicts and
effect a sense of relief, freedom and reward.
Psychotherapeutic efforts are directed towards
building on the positive and healthy parts of the
patient, that aids in remotivating that person to
look towards reality, rather than wallow in the
defenses that the psychosis has persuaded her to
build. If properly nurtured, this first step, the
establishment of relatedness, leads to a
collaborative effort that becomes an alliance
between the patient and psychotherapist. Without
this alliance, there is no treatment. However, it is
essential that we understand the treatment alliance
is not necessarily constant during the course of
psychotherapy and the allied treatment modalities.
The psychotherapist and other members of the
treatment team and the patient often, unconsciously,
say or do things that rupture or break the alliance.
The treatment team must always be alert and
sensitive to these possibilities and should it
happen, bend their collective efforts at repairing
the breach in this critical relationship. This
rupture in the alliance happens with some frequency
as the struggle to change takes place. However,
every time this breach in the alliance is resolved,
the relationship becomes stronger.
I must repeat, it is critical for the
psychotherapist to understand that treatment that
leads to corrective behavioral changes cannot take
place without making contact with the patient that
leads to a therapeutic alliance. Let me add, that
even those psychiatrists who prescribe medication,
must develop such a relationship with the patient in
order for medication to have a maximum effect.
Psychotherapy can be called strategic if the
clinician initiates what happens during therapy and
designs a particular approach for each problem. He
must identify solvable problems, set goals, design
interventions to achieve these goals, examine the
responses he received to correct his approach and
examine the outcome of his therapy to see if it has
been effective.
During the first half of this century, clinicians
were trained to avoid planning or initiating what
was to happen in therapy and to wait for the patient
to say or do something. Only then, could the
therapist act. Under the influence of
psychoanalysis, Rogerian (Carl Rogers) therapy and
psychodynamic therapy, the idea developed that the
person who does not know what to do and is seeking
help, should determine what happens in the
therapeutic encounter. The clinician was expected to
sit passively and only interpret or reflect back to
the patient what he was saying and doing. He could
offer only one approach no matter how different the
kinds of people or what the problems were. This
passive approach lost for the clinical profession
many effective therapeutic strategies. Strategic
therapy is not a particular approach or theory, but
it is simply a name for those types of therapy where
the therapist takes responsibility for directly
influencing people.
Before and in the 1950's a number of strategic
therapists began to grow. Family therapy and the
conditioning therapies and the direct therapies
started with the early Freudians and continues now
with the work of a growing number of active
psychotherapies.
Today, the issue of psychotherapy with schizophrenia
is confusing to many people in the field, because of
the conflict between active and passive methods of
interaction. We should understand that decades ago,
psychotherapists were persuaded to stop talking and
start listening. So completely was this achieved,
that the great need today is to start the
psychotherapist talking again. It should be clear
that the contributions that the older
psychotherapies have made, need to be acknowledged,
but experience has pointed out, I believe, that this
is the time for active therapies that stand in the
sharpest contrast to psychoanalysis, both in their
techniques and in their claims to be seen, as a
result of studies in many parts of the world.
Psychoanalysis has proven itself remarkably able to
understand patients, but point to the extraordinary
difficulty it has changing the patients behavior,
despite frequent and prolonged contact. Active
therapists have been more successful in changing the
patients without the same understanding of
traditional psychotherapy and psychodynamics. We
must always be open to change, as outcome and
research studies mandate the need for change.
I will make an effort to point out some of the
significant features of direct confrontation.
However, it is critical that one understands that
confrontation is more than an overtly aggressive
method of dealing with the long term schizophrenic
and that one understands that confrontation can be
subtle, with many other variations. Also, that it is
a unilateral effort on the part of the
psychotherapist that is basically designed to
intrude on the patients sick behavior and disrupt
the psychosis and produce different sets of behavior
that are more consistent with the expectations and
demands of society. The following will include the
strategies that both the patient and the
psychotherapist use in their respective efforts. The
patients efforts at retaining her psychotic
equilibrium and the therapists efforts at breaking
down these defenses.
Confrontation can be seen as a forceful
intervention. The psychotherapist may make his
remarks in a forceful rather than in a gentle
fashion in order to make sure his patient hears what
he has to say. However, depending on the patient as
a unique individual, a gentle way of stating
something or a bit of humor might confront her with
something she has resisted.
The term "force" can disturb people if it is not
understood as being demanding of the patient to meet
the treatment criteria. It is not in any sense
abusive or disrespectful of the patient. We can not
forget that psychotherapy with long term
schizophrenics is an influence process. We use
psychotherapy to promote change. Many patients are
not changed by insight, simply because the illness
serves as a survival system and the patient refuses
and fights against change.
The psychotherapist when he confronts, has in mind
getting the patients' attention, producing a
reaction in her and demanding that she change. The
strategies the psychotherapist has at his disposal
are his own emotions and his understanding that he
needs to use language to create a sense of reality
in the patient. The psychotherapist must use words,
at times, to shock the patient and make her aware
that she is facing a person who is different than
the other psychotherapists she has seen in the past.
One of the important points of confrontation is
unmasking or uncovering denial, which can take many
forms. Another important treatment issue is making
the patient aware of any behaviors that lead to
disrupting regressive reactions, letting the patient
know how her regressive unappreciative demanding
behavior effects other people, including the
therapist and that their are conditions to a
relationship and that some behaviorisms are just not
acceptable. He must insist that the patient become
responsible for her behavior and that she control
her impulses.
As one uses confrontation methods properly, I
believe they tell the patient that the therapist has
a genuine interest in her and wants to help. Also
that the psychotherapist is stronger than the
overwhelming aspects of the patients' schizophrenia.
There is a sense of safety and security in this
realization. The character structure of a patient
can determine her response to a confrontation, it is
important to continue the confrontation as long as
the patient distorts her perception of the
psychotherapists meaning and continues to manipulate
those people who are treating her in order to
perpetuate her condition. Anger on the the
psychotherapists part is not necessarily counter-
transference, but should also be seen as one human
beings response to another persons unacceptable
behavior. We must accept the reality of our emotions
in the context of treatment and in an acceptable way
permit the patient to know how we feel about her.
Confrontation is helpful in establishing a
therapeutic alliance and useful in reconstructing
the healthier defenses in the patients' life when
the disturbed defensive strategies of the patient
are overcome.
This in brief are some ideas that can actively
involve the schizophrenic patient in treatment.
Until we meet again,
Jack Rosberg
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