Mental health professionals are being called on to provide community treatment for increasing numbers of long-term schizophrenics. Despite the effectiveness and cost efficiency of social and drug therapy, individual psychotherapy can play a central role. But first there must be a clearly understood point of view and rationale, so that potential therapists do not turn away from the task in confusion and dismay. In the state hospital, the long-term schizophrenic was seen and saw himself as helpless and incompetent. It is important not to dismiss him as also being incapable of using psychotherapy.
The trend in psychotherapy for schizophrenia has been towards a decreasing interest in psychopathology and an increasing interest in practical issues of adaptation.1 It focuses on reality rather than fantasy, on the present and future rather than the past. It does not, however, exclude using the past to understand the present and to predict future possibilities. Controversy exists as to whether regression is to be encouraged or discouraged in the treatment of schizophrenia. My opinion is that it should be discouraged. The psychotherapy described in this article emphasizes the exploration of the patient's problems and the stresses that precipitate them, as well as on the psychotherapeutic relationship itself - two aspects of therapy that complement each other. Above all, there is emphasis on the long-term schizophrenic's achieving the mastery and heightened self-esteem that come with knowing he can cope with his illness and the demands of his world.
Insight is a goal for the long-term schizophrenic patient. Insight must be defined, however, so that the therapist and his patient understand what they are striving for. Insight means that, for the patient, such symptoms as delusions, hallucinations, and feelings that he is "falling apart" are understandable; he is under stress and is reacting to it. After helping the patient see this much, the therapist works with him to see that logical, purposeful actions can follow from such insight. The patient must not panic, but must try to understand the stress that is producing the anxiety and hence generating his symptoms. Having identified the stress, therapist and patient must next determine what actions should be taken to solve the problem. In the meantime, the patient must understand that increasing his medications will alleviate his symptoms and help maintain his problemsolving abilities. Insight is crucial to the treatment of the long-term schizophrenic. It is a matter of understanding what kinds of situations are extremely anxiety provoking for him and how to deal with or avoid these situations, how he interacts with family and friends and how these interactions need to be changed.
A 46-year-old married woman had had numerous state hospitalizations for psychotic episodes for 15 years. She had been out of the hospital for two and a half years and, although taking fairly high doses of psychoactive drugs, continued to have occasional paranoid delusions. When especially upset, she was certain that everyone was saying that she ate her feces.
Many of her early weekly sessions with her therapist centered around helping her see these delusions as symptoms, indicators that she was anxious and under pressure. She was at first skeptical but, since she had a positive relationship with her therapist, was willing to entertain this concept. After four or five sessions she was able to say, "I must tell you that I understand this on an intellectual level but I'm not sure that I really believe it down deep. But I trust you, so I'll operate as if I really believed it." By examining her symptoms each time they occurred, she was able, with the therapist's help, to identify the particular stress that had precipitated them and formulate a course of action that would resolve the situation. After about six months of this kind of work in therapy, she was finally able to talk about the delusion of people saying that she ate her feces, and in turn got some perspective on the fact that at such times her anxiety was especially severe. She seemed much relieved by being able to understand the symptoms as indictators of anxiety instead of experiencing them as very frightening feelings that seemed real, incomprehensible, and beyond her control.
A therapist who sees his patient beginning to decompensate under stress will, of course, take some immediate action. Sometimes he can alter the patient's environment to prevent or reverse this decompensation. But it is important that the patient be aware of the reason for action taken to alleviate stress, and be as much a participant in it as possible. Eventually the patient . can incorporate this active process of identifying and dealing with stressful situations, based on an identification with the therapist.
The frequency and intensity of one-to-one therapy should be adjusted to the patient's tolerance; sessions can be for one hour a week, one hour every other week, half an hour a week, half an hour once a month, or whatever seems appropriate. Except in times of crisis, therapists should be reluctant to see a schizophrenic patient for more than one hour a week, because of the danger of developing a transference that neither therapist nor patient can handle. Schizophrenics generally have difficulty handling the closeness and regression that develop in intensive psychotherapy. To ignore this is to invite a transference psychosis.2
A 32-year-old married woman started outpatient therapy following a psychotic episode that had required hospitalization. It soon became clear that she had had a thought disorder for a number of years. In the first interview she became extremely anxious and insisted that her husband be called in from the waiting room. She was unable to explain what had happened, but did ask that her husband be with her in subsequent sessions, and the therapist agreed. There were numerous problems in the marriage that needed to be discussed, and the patient seemed to feel free to talk about other problems in her husband's presence. Once, when she arrived before her husband, she again became very anxious and again could give no explanation.
Therapy progressed well, and after about two years it was agreed that regular visits were no longer necessary but that either she or her husband could call for an appointment if any problems arose that they could not handle together. Inis they did, coming in approximately once a year for a joint session. But about seven years after her first interview, the patient called and requested to come in alone. On arrival, she reported that her life in general and her marriage were going well, but she had two special reasons for coming. First, she wanted to tell the therapist that her initial problem had been that she was afraid she would lose control of herself and ask the therapist to have sexual intercourse with her in his office. Second, she felt that she now had more control and wanted to be able to prove to herself that she could sit in the office with her therapist and maintain control, which in fact she did. Further discussion revealed that beneath the concern about sexual intimacy was a more basic general fear of losing control and being "at the mercy" of another person in a close relationship. She had used her husband's presence to dilute the relationship with the therapist and, without realizing it, had prevented what would very likely have become a transference psychosis.
Other techniques that keep the patient's anxiety at a manageable level can be appropriately employed. Long silences should be avoided; rapid eruptions of unconscious material should be discouraged.
STRENGTHENING EGO CONTROLS
There is a popular notion that if a therapist can help a patient "express his anger," something very therapeutic has been accomplished. And indeed this is often true, especially with nonschizophrenic patients. But with long-term schizophrenics, a sudden explosion of anger may really be a psychotic loss of control that may lead to further loosening of controls generally and quite probably to hospitalization. Appropriate expression of anger over which the patient has control can be an important longterm treatment goal. On a short-term basis one should be cautious, paying fully as much attention to patient's ability to retain control as is paid to the underlying anger.
A 41-year-old man with chronic schizophrenia had been able to function quite well in a minor executive position between his infrequent psychotic episodes. Each episode, however, had been characterized by extreme anger and paranoia. In remission he was a pleasant, friendly man with little overt hostility, universally described as a "nice guy." In therapy, each time the therapist allowed him to express any real degree of anger, the patient began to decompensate. So, during the first few years of therapy, the patient was encouraged to suppress his anger; each time, he pulled himself together and continued to function well.
As the relationship progressed and the patient felt more confident that his therapist would support him if he began to lose control, he started to assert himself, at first in small ways and later in more significant ones. It was a slow process, but after four years the patient was able to become overtly angry at his wife and more aggressive at work without losing control, disrupting his marriage, losing his job, or requiring hospitalization. He now has a feeling of mastery over his angry impulses that is very gratifying to him, and he enjoys his much improved relationship with his wife, employer, co-workers, and others.
A similar snare that awaits the unwary therapist is the temptation to try to change the character structure of a schizophrenic with a "sickly sweet" exterior covering what is clearly a tremendous amount of hostility. In the short term such a character structure is best left intact as a necessary defense against psychotic loss of control over angry impulses. In some cases changes can be effected over a long period, but often this trait is so necessary to help a weak ego deal with immense anger that little or nothing can be done to change it. Therapists must content themselves with settling for what is possible, and even though a character defense may annoy the therapist, it is far better than an overt psychotic break.
Another way to help patients develop ego control is to keep them thinking in realityoriented terms and prevent them from drifting off into ruminations about primary-process fantasy. For instance, a schizophrenic woman begins talking about a dream in which she had intercourse with her father. There is a great temptation to get into a discussion of oedipal feelings, incestuous tendencies, and all the dynamics that easily flow from such a dream. It would probably make a fascinating hour. But that evening or the next day, one is quite likely to have to deal with an overtly psychotic patient. One should not ignore such material, but help the patient repress it. The therapist can say, "You love and miss your father, and sometimes it shows up in dreams like this. The sexual part of the dream disguises the feelings of closeness you had for him." If it seems desirable, patient and therapist can then discuss the father in terms of reality. As this process is repeated in therapy, the patient herself learns how to turn away from primary-process material; with her ego more intact, she feels better equipped to grapple with the problems in her life.
Ego control can be supplemented by having the therapist set limits on behavior: "Don't stop therapy, continue taking your medications, don't impulsively quit your job." Often, loss of the therapist's approval is in itself sufficient incentive for the patient to adhere to limits set by him. Occasionally the family can contribute to enforcing limits. At the outset, the patient only complies passively. In successful therapy, however, the limits are internalized, strengthening the patient's inner controls and enhancing his ego functioning and his feeling that he can control his own destiny.
Many long-term schizophrenics lack the ability to cope with the routine stresses of life. By discussing these stresses in individual therapy, the patient is helped to resolve problems with which he cannot cope alone. Sometimes this is done as it would be with more healthy patients: the therapist acts as a catalyst, enabling the patient to identify the alternatives and choose the one right for him. In other cases the therapist may give direct advice. This may not come easily to the therapist, but it may be crucial to the success of therapy. Sometimes the same advice needs to be given over and over again, but the patient usually learns new ways of handling situations; at the time of the next crisis he should be able to arrive at the solution himself.
A 36-year-old married woman had been hospitalized five times for acute psychotic episodes between the ages of 20 and 31, but for five years she had been doing well in outpatient psychotherapy. She was on vacation, visiting her mother in another city, when she called her therapist, obviously disturbed and in the incipient stage of a psychotic episode. Unraveling the story over the phone, the therapist finally ascertained that she had been going through her mother's cedar chest and bringing out all sorts of mementos from the past. Finally she had come across a birthday card she had received from her late father on her Ulli birthday, on which he had written, "Happy birthday to a good little girl who is doing the dishes on her own birthday." She was flooded with memories of the deprivation she had experienced as a child, of the unreasonable demands that had been placed on her, and of the feelings of loss for her dead father, about whom she felt quite ambivalent. The therapist's response was, 'Tut all those things back and close that cedar chest." The patient complied, and when she called back an hour later she was much less distraught; she now felt in control of the situation, and a psychotic decompensation had been averted. In succeeding visits over the years she did not reopen the cedar chest, either literally or figuratively.
Persons from the lower socioeconomic classes, in particular, expect a professional to give advice, and therapy may fail if the advice is not forthcoming.3 Nothing is more difficult for many therapists than to give direct advice and to give it in simple language without jargon. The following example, however, illustrates what can be accomplished if the therapist feels free to do things that are very different from what is usually described as psychotherapy.
A middle-aged schizophrenic woman hospitalized for psychotic depression after her husband had impulsively left her; the reunion when he returned was not exactly a joyous one, but the patient went into remission and the marriage continued. The patient refused regular outpatient treatment but did call at times of crisis, and each time there was direct intervention by the therapist and the patient did not have to be hospitalized.
One day she called, very disturbed, talking about suicide, and unable to give a clear explanation of what the problem was. She arrived for the interview with her husband, a burly, unsophisticated, but long-suffering and wellintentioned truck driver. A half-hour of exploring all the known trouble spots in this couple's lives finally revealed the problem. The husband had been waging a campaign for the past year to induce the patient to go out more, spend less time with her mother, and have some social life; since she had no teeth, he had prevailed on her to get dentures as a first step in making herself presentable in public. The patient repeated over and over again, "My dentures do not fit and so I am going to kill myself." Clearly, what she meant was that she did not want to change her way of life and was very angry at her husband for attempting to force her to do so.
The therapist and couple had been through this issue of increased time outside the home many times, and this time the therapist took a directive stance. To the husband he said: "Joe, I realize that these dentures cost a lot of money and you really resent your wife for not wearing them, and that it bothers you very much when she won't go out with you. But I don't think there's any way to change the situation. If you want things to settle down at home and the kids to be less upset and your wife not to end up in the hospital, I think the best thing for you to do is to forget about the dentures and leave it up to your wife whether or not she wears them." The husband groaned, but seemed to realize that it was a question of either accepting the situation or leaving home again, which he was psychologically not prepared to do. "Fine," said the patient, "then I won't wear them." The therapist then said, "No, Roseanne, I don't think you should leave it at that. You should at least go with your husband to his union picnic. If s very embarrassing for him not to show up, year after year, and you owe it to him to attend and to make yourself look presentable when you do." She, in turn, groaned but agreed to do this. A call from the patient a week later revealed that both parties had abided by their agreement and the situation had returned to its usual unsatisfactory equilibrium. Despite the complaints of both, husband and wife seemed to be able to live with the situation and even derive some gratification from it. The patient no longer needed to become psychotic to resolve impasses with her husband, as she knew that she could call the therapist for advice and arbitration.
Frequently it is helpful to assist the patient in rationalizing a situation, saving face and selfesteem. Take, for example, the man for whom being in psychiatric treatment means that he is sick, inferior, and a failure as a man. Often these feelings can be dealt with in time, but at the moment the important thing is to keep him in treatment and his illness in remission. The therapist might say, "You know how concerned your wife is about you and how fearful she is that you will have another breakdown. The more worried she gets, the more she upsets you, and the more upset you are, the less you can function at work. So it is really important for you to remain in therapy, because that way you relieve your wife's worry, make her life more comfortable, and in the process make your own life more comfortable." Of course, this should be said only if the wife does in fact have this reaction. Still, it is only a part of the picture. But it is a rationalization that helps the patient remain in treatment while he retains the image of himself that is necessary for his psychologic well-being.
TAKING SIDES AGAINST THE SUPEREGO
Sometimes the therapist can best help the patient by taking sides against his superego, decreasing guilt and the self-destructive behavior that it prompts. In many situations the patient will react to a situation in a self-destructive way because of lifelong, inappropriate feelings of guilt, and the therapist must not only point this out but also say, "That is self-destructive. Don't do it."
A 31-year-old woman was constantly re^ minded during her childhood, by parents and siblings, that her role in life was to compensate for the failings of her alcoholic mother and care for her father and brothers. She had been made to feel that any gratification or enjoyment of life was wrong, that she should instead be devoting herself to the welfare of her family. As an adult, simply taking an enjoyable vacation was enough to overwhelm her with guilt and precipitate a psychotic break. Early in therapy, her therapist's statement, "It is not wrong to enjoy a vacation," reduced her guilt and helped her to both enjoy the vacation and not become symptomatic. But it was an external and foreign way of viewing the situation. As therapy progressed, the reduction in guilt became internalized, her superego became modified, and the patient became less dependent on the therapist to deal with and master what had been disabling guilt. Eventually she learned to enjoy taking vacations, buying and caring for a new house, and having intercourse, realizing that such enjoyment was important not only for her but also for the welfare of her husband and children.
Another woman felt tremendous resentment against her husband for the way he was treating her, but she felt that she was exaggerating his behavior and in any case had no right to feel resentment. Her therapist had known the family for over 10 years and was in a good position to assess the situation. His response was: "You are not at all exaggerating the way he is treating you. And it is a normal, human response to feel resentment about such treatment. Part of the problem is that your parents made you feel that all angry feelings are wrong. It is normal, it is all right, to feel resentful about this." This reduction of guilt helped the patient come out of her depression and lessened her need to use psychotic defenses in dealing with her guilty feelings.
These examples illustrate a crucial point that is too often neglected in community mental health, the importance of understanding individual psychodynamics in long-term schizophrenics. Aftercare programs consisting primarily of medication and social therapy, even when good relationships and close involvement are present, are often superficial. One can find a happy medium between the formal psychoanalysis of the schizophrenic patient and a program consisting only of medications and group activities. It is important to understand the psychodynamics of the patient's illness, have at least a modicum of information about his early life, and in particular understand how real-life situations interact with his internal dynamics to cause a psychotic episode, interfere with growth, or deprive him of gratification from life. Mental health workers need not apologize if their work is not analytically oriented psychotherapy delving into the patient's childhood; likewise, those in community psychiatry should not feel apologetic about delving into the patient's psychodynamics to deepen their understanding of what exacerbates or relieves his illness.
The first requisite in treatment of the long- term schizophrenic is that he understand his symptoms as reactions to stress. From this un- derstanding can come practical resolutions of his problems and the most important aspect of this type of therapy, a sense of mastery 4 over his internal drives, symptoms, and environ- mental demands. With this feeling of mastery comes a sharp rise in his self-esteem and feel- ings of self -worth. It is in this context that re- gression, especially in the form of continued psychotic experiences as advocated by some,1 is seen as contraindicated. Such experiences un- dermine the person's self-confidence and rein- force his conviction that he is living in a world where he will always be at the mercy of power- ful forces, both internal and external, that are beyond his control.
Flexibility on the part of the therapist is also important. He must work in the present but be able to delve into the past when necessary. He may at one time serve as a catalyst while the pa- tient does the actual decision making, and in the next hour be equally comfortable as a direct ad- viser, a setter of limits, or both. He must be able to determine when his task is to strengthen the ego and when it is to take sides against the superego. He needs to establish a warm, mean- ingful relationship without exceeding the patient's tolerance for closeness and intimacy.
In short, he must modify many of the tech- niques that he learned for working with patients who had quite different problems. But we can accomplish a great deal in psychotherapy with long-term schizophrenics. They were formerly relegated to the back wards of state hospitals; we should not now relegate them to the back- wash of community mental health. ®
1. Gunderson. J. G. Controversies about the psychotherapy of schizophrenia. Am. J. Psychiatry 130 (1973), 677-681.
2. Fox. R. P, Therapeutic environments. Arch. Gen. Psychiatry 29 (1973), 514-517.
3. Carlson, D. A., et al. Problems in treating the lower class psychotic. Arch. Gen. Psychiatry 13 (1965). 269-274.
4. Feniche!, O. The Psychoanalytic Theory of Neurosis. London: Routtedge and Kegan Paul. 1946. pp. 13. 460.