Treating the 'Untreatable'

Healing in the Realms of Madness

Ira Steinman

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429923371
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Treating the 'Untreatable' offers the hope of recovery, healing and cure for the most severe psychotic disturbances, schizophrenia and delusional disorder. Through a psychotherapeutic exploration of hallucinations, delusions and thought disorder, even the most hopeless and "untreatable" patients have a chance for returning to a life of relationships and function even after years, if not decades, of disturbance. These studies in the intensive psychotherapy of schizophrenia and delusional disorders demonstrate that recovery, healing and cure can be achieved in those most disturbed. In this era of treating schizophrenic and delusional patients with a primarily antipsychotic drug oriented approach, a more thorough exploration of the meaning to the patient of his psychosis - with judicious antipsychotic use, when indicated - leads to internal character and external behavioral change that is far more lasting than with antipsychotic use alone. With such a psychodynamic approach, some of these previously chaotic, disturbed and heavily medicated people were able to understand the symbolism and the origin of their psychotic productions and go off antipsychotic medication altogether.

CHAPTER ONE
Delusional reality

A person's behaviour is determined by his conscious and unconscious beliefs. We each have a Weltanschauung, a belief system that guides us and serves as an internal compass. Some people have trouble if their convictions conflict with each other; this is the pain of neurosis. Some have a great deal of trouble if their beliefs collide with other people's beliefs; here, issues of insecurity and conformity become paramount. Some people stick to their convictions about generally agreed reality in the face of all evidence to the contrary; this is the realm of psychosis and delusional belief.

A delusion is a firmly held belief in something false, a belief in something untrue for the rest of us, a set of ideas and concepts that guide and predetermine a person’s behaviour, without adequate external corroboration. By definition, a delusion is clung to in the face of objections and rational arguments from others. Delusions make it impossible for a person to accurately perceive and function in day-to-day life.

Delusions occur in a number of different diagnostic categories. In schizophrenia, where there is a withdrawal of energy from the external world, auditory hallucinations and diminished social and occupational functioning often go hand in hand with fixed delusional ideas. In paranoid delusional disorder, occupational functioning may persist in the face of bizarre and self-referential ideas which make it extremely difficult to maintain personal relationships. In multiple personality disorder, delusional beliefs about the composition of one’s own self make it very hard to function as an integrated being. And of course, mood disorders may have a delusional component ranging from manic, inflated grandiosity and megalomania to the depressive, hypochondriacal and deflated self.

People with delusional beliefs and schizophrenic thought become mired in their own misconceptions and misperceptions, burrowing further into a rigid solipsistic orientation towards life. Psychological energy is withdrawn from the external world of people and things and focused on the internal delusional reality. Internal reality, highly energised or cathected, takes precedence over the world the rest of us live in. Attempts to redirect and reorient a delusional person are often doomed to failure. The pattern of such a person is far more likely to become one of repeated hospitalizations and deterioration. For relatives, friends and therapists, delusional people appear immutably stuck and “untreatable”.

Delusional people misperceive and orchestrate events internally in very strange ways that mean little to most of us. Passing cars, a chance glance, a word uttered between two people who have no relationship to the delusional person, all take on specific, idiosyncratic meaning. Words and sounds have unique symbolic and self-referential connotations, as do world events. For such people, anything might mean anything. The colour of clothing, advertisements, and newspaper stories might mean one thing to one delusional person and something quite different to another delusional person. Such a person may be able to carry on conversations but, unbeknown to us, mean something quite different from what we mean. To me a black hat is a black hat, but to the schizophrenic person blackness may be the spur of a train of associations leading to witches or a similar tangent to the shape of the hat and someone in another state who had that shape hat or toolbox. Sometimes the schizophrenic or delusional person is actually filtering everything through third and fourth parties, seen only by him and with whom only he can communicate.

Delusions come in all modalities and forms. There are visual, tactile, olfactory, gustatory, auditory and thought delusions. Some have delusions of persecution, omnipotence, and influence. Others have somatic (bodily) delusions, an extreme form of hypochondria. Depending on one’s mood, delusions may be of grandeur, if elated, or self-accusation and remorse, if depressed. There is delusional litigiousness and pathological jealousy. Still others live in worlds populated by long gone or imaginary people.

A person with delusional beliefs might be certain that the sound of a car in the street means that there is a communication to him in that sound. Perhaps he is convinced that a passing person’s gesture with the right hand means one self-referential thing; with the left, another. Old movies and television reruns might be speaking in an extremely personal way to the viewer, including him in the dialogue in a way that the movie director never intended when he made the film years before. Day-to-day events and realistic data might be filtered through the medium of a comforting and engaging being, a protector, or through the constant criticisms of an angry, torturing being that no one but the patient can see or hear.

Worlds not readily seen by others are revealed to the delusional patient through the ingenuity and activity of his mind. Newspapers, magazines, television ads, billboards, even the passing words of a pedestrian are reinterpreted. Perhaps one’s teeth are wired, one’s thoughts monitored, one’s every reaction noted by the powers that be in a far distant place. Perhaps machinery or satellites are involved in a constant oversight of one’s own thoughts and feelings.

These strange readings of events are of paramount importance. The delusional or schizophrenic person is trying to make sense of the world he lives in. He may do it in bizarre ways, but there is a logic to delusions, if one spends enough time exploring them. Perhaps stimuli are overwhelming; perhaps childhood fears and expectations are placed on seemingly innocuous situations. Perhaps grandiosity is a cover for a feeling of worthlessness; perhaps paranoia is feared retribution for imagined danger or, in other circumstances, punishment for fantasies or actions.

When one is vulnerable to forming delusions, “perhaps” quickly becomes certitude, which becomes a rigid paranoia with no outlet, as misperception builds on fear in a constant attempt to catch up with or get one step ahead of the alleged torturing powers.

A delusion is a creative compromise, albeit unrecognised, on the patient’s part. It contains the encoded message; undeciphered, it wreaks havoc and destruction in the mind and being of the delusional person. It is an extreme, all or nothing solution to emotional and intrapsychic difficulties.

Some people are vulnerable to forming delusions or hallucinations. Is this the result of a constitutional or genetic defect? In such people, is the forebrain or the cortex of the brain damaged in some way? If there is neurological damage, is it congenital or is damage the result of life’s experiences and the subsequent enhancement of neural pathways of unmodulated anxiety and terror? Does painful psychological experience lead to a surge of alerting brain chemicals and the consequent laying down of neural pathways that heighten fear, with an attendant retreat to delusions and hallucinations as vain attempts at self-soothing through the creation of imaginary worlds?

I think this book will answer such questions along the lines of schizophrenic thought and delusions being the result of the psychological effects of life’s experiences. Even if there is some inborn constitutional vulnerability, as opposed to an environmentally induced one, the same treatment message applies: an intensive psychotherapy of schizophrenic thought and delusions may lead to an ameliorative, perhaps curative effect, if we only try.

Rather than using left brain rational thought, the schizophrenic is overwhelmed by the alleged certainty of right brain intuitive processing. Instead of parsing his or her own productions—ranging from delusions to hallucinations to bizarre conjectures and apprehensions which are unrealistic and unwarranted—through a logical left brain perspective, the psychotic patient affirms the “reality” of his or her own creations in the face of all evidence to the contrary.

Once one is delusional, there is the propensity to develop all types of delusions. The small child’s belief that she came from outer space seems innocuous enough; it can, however, lead to delusion formation, should external and internal difficulties in life present themselves. Delusional people have a mindset of unreality, handling life’s difficulties through the medium of wishes and fears they believe in. Gradually, thoughts, images and mind schemes become more real than the consensually validated reality in which we all live. Once one is psychotic, it is a small step to become ensnared by one’s own creative processes, one’s delusions and hallucinations, as psychological energy is withdrawn from the generally agreed world we live in and focused on the internal chaotic world. At this point, the schizophrenic or delusional person is mired in the realm of psychosis.

But, like the Rosetta stone or the double helix, fathoming the origin of delusions and schizophrenic thought opens an avenue for tremendous insight into the mind of the delusional patient and gives us the possibility for therapeutic change and healing.

CHAPTER TWO
The psychotherapy of delusional states

In the field of treating the very disturbed and delusional, there is a long tradition of offering humane environments and understanding psychotherapeutic attitudes that can lead to the melting of psychosis and the dissolution of delusional ideas. This is wonderful when it happens; medication, group and psychotherapeutic support may heal the isolation that leads to withdrawal into delusional beliefs. Unfortunately, fewer and fewer of these humane environments are available. When they are available, little attention is focused on the symbolic meaning of delusions and hallucinations to patients, with the result that schizophrenic and delusional patients are often objectified and treated as the "other". A primarily antipsychotic medication approach furthers the view that psychotic patients are different from us and that their productions have little meaning.

Hopefully, Marius Romme and Sandra Escher’s “Hearing voices Movement”, artfully chronicled by Daniel Smith in Muses, Madmen, and Prophets (2007), will begin to have an effect on how patients and therapists see hallucinations and delusions. But here too, it will be necessary for patients and therapists to fully comprehend the symbolic meaning of each patient’s creative productions, and use antipsychotic medications judiciously, rather than just waiting for the right antipsychotic medication to get rid of the voices.

This book is about those severely disturbed patients who did not respond to the best humane ministrations and who were too ensnared in their delusional beliefs to benefit from the routine practice of psychotherapists and institutions. For these critically ill patients, I suggest a more radical yet (in the long run), conservative approach.

It is the purpose of this book to articulate the position that there is a psychotherapeutic treatment, a simple and time-honoured one, which is useful in treating such schizophrenic and delusional people: take a history of the origin of schizophrenic thought, hallucinations or delusional beliefs, and sit with the person as he or she goes through various therapeutic phases, as both patient and therapist try to make sense of hallucinations and delusions from a psychological perspective, gradually understanding the patient’s unique symbolism. It is a corollary of the first principle that such an inquiry will drive a wedge between the patient and his psychotic beliefs. In such a process, psychic energy is gradually taken away from the internal world of delusion and hallucination and returns to where it more naturally belongs, to the world of people and things and external interests.

The process of psychotherapy with delusional patients may, on occasion, be a short one, as the patient quickly grasps the symbolic meaning of his delusions or hallucinations and the feelings underlying such a delusional orientation pour out. Such a resolution is infrequent. More usually, the period of psychotherapy aimed at helping the patient overcome a schizophrenic or delusional orientation will be a long and arduous one, with change measured in infinitesimally small increments. Long intervals of seeming stasis must be tolerated by both patient and therapist in the face of what may appear to be gridlock, if the process is to bear fruit.

It is of the utmost importance that the therapist considers the possibility that schizophrenic thought and delusional beliefs will respond to a psychotherapy oriented towards understanding the symbolic meaning to the patient of delusions and hallucinations, as well as towards discovering, uncovering and elaborating the origin of the distorted beliefs. Therapist and patient must come to understand the confluence of external events and emotional and psychological reactions that led to the formation of delusions and hallucinations. Most importantly, the therapist must realise that there is a “method in this madness”. He or she must understand that psychodynamic factors underlie seemingly intractable delusional beliefs.

Delusional people are often in great pain. Yet, for a delusional person it is often easier to believe one is God’s chosen spokesman than to feel weak, unloved, fearful, tearful and powerless. For some, it is more acceptable to live in terror of the Mafia than to deal with fears, loneliness and unacceptable impulses that existed from childhood. It is easier to fear other people’s intense sexual interest in oneself, as seen in their every word and gesture, than to deal with one’s own lust, sense of worthlessness and fear of rejection.

Treatment itself may become a source of delusions. Even though we know that the treatment setting (the container of psychotherapy) is a safe and comfortable one, delusional people may not view it so. We may represent frightening figures; the office may seem bugged; a conduit to the persecuting outside may somehow appear to be present in our communications. These negative issues need to be unearthed and discovered, then looked at and elaborated upon, if change and progress are to occur.

What is necessary is a two-pronged approach. Of crucial importance is the understanding of the schizophrenic or delusional person’s life and a comprehension of the beginning and further development of the psychotic beliefs. Just as important is the simple act of sitting with the frightened, emotional, often unloved self, sensing and feeling and empathically responding to and corroborating accurate readings of the situation between patient and therapist. It is only in this psychotherapeutic relationship that healing, change and growth may occur.

In this type of uncovering psychotherapy one embarks with the patient on a psychic journey that gradually leads to what Harry Guntrip called “the lost heart of the self” (1968). Here we rest, the patient to mourn past losses and grieve about past abuse or intrapsychic terrors. Imperceptibly, he or she takes solace and comfort in the therapeutic relationship, uncovering and exploring the various beliefs and reasons that played a part in becoming so confused. Little by little, he or she gathers strength through our reliving the emotional and psychological causation of his or her disturbance. Slowly, ever so timorously, this previously unsalvageable person emerges from the chrysalis, a sensitive soul beginning the passage back to our consensually agreed reality.

When I first began to encounter such convoluted and fragmented people in medical school, I thought the Alexandrine sword of reality testing would quickly cut through the Gordian knot of such irrational beliefs. It didn’t take long for me to realise that this had been tried numerous times before, with the result that patients suffering from such disordered thinking only retreated further into the maze of self-deception, which now might include the perception of an attacking therapist.

Since reality testing didn’t cut through the labyrinth of delusional distortion, I began to wonder what would happen if we, as therapists, tried to “walk in the moccasins” of the delusional patient. After all, why would a person act and think in such a way unless it made some kind of sense to him, or he was stuck in something that once made sense? I believed it was essential to take a history of the origin of the delusional beliefs. I began to see that such a gradual therapeutic unwinding of Ariadne’s web of disturbed perception, thought and behaviour began to release from delusion people who had been trapped in psychotic thought, even after a number of decades.

The difference appeared to be that the slow process of psychodynamic exploration of the development of delusional beliefs had not been seriously tried before with these people, even though many had had numerous hospitalisations, psychotherapies and trials of medications. Other practitioners had not had the courage of their psychodynamic convictions and had doubted that any serious therapeutic inquiry would bear fruit. They had not travelled with their patients through the numerous twists and turns and detours encountered in an exploratory psychotherapy of delusions. In using this psychotherapeutic approach over the last forty years, I have found that gradually, sometimes ever so slowly, intrapsychic and behavioural change could occur in once lost and delusional patients. This finding however, as demonstrated in the cases set out in this book, runs counter to the current beliefs as to what is possible with such patients.

The psychotherapy of delusional states has become a nearly lost art in this era of antipsychotic medications. Although medication can be very helpful, and at times essential, there are a number of reasons why antipsychotics alone may not help. Some patients hate the side effects, even of the newest antipsychotics with their destructive glucose and lipid metabolism alterations. Some refuse medication for philosophical and delusional reasons. Some, even with antipsychotics, merely go underground, with the persistence of beliefs that preclude intrapsychic change and genuine functioning in reality. For example, a delusional person on antipsychotics may be passing a cup of coffee to a long dead relative while appearing to be in reality with us. At some point, such an unexamined and fragile arrangement may fracture, with the risk of the patient becoming openly psychotic.

If medication as the prime treatment modality does the trick, the patient is better off very quickly. I certainly have seen numerous patients who responded to antipsychotic medication with definitely beneficial effects; such patients are relatively easy to treat. However, none of the patients presented in this book ever found or took enough medication to keep delusional beliefs under control. Some refused to take medication at all, or were reluctant to take enough antipsychotic medication. Others took very high doses of antipsychotics, with little or no diminution of delusional beliefs.

It is not an either-or situ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Dedication
• ABOUT THE AUTHOR
• PREFACE
• CHAPTER ONE Delusional reality
• CHAPTER TWO The psychotherapy of delusional states
• CHAPTER THREE Causes of a delusional orientation
• CHAPTER FOUR The method
• CHAPTER FIVE The history of the psychotherapy of schizophrenia and delusional states
• CHAPTER SIX Psychotherapeutic technique and stages in the psychotherapy of delusional states
• APOLOGIA AND CLINICAL PRESENTATION
• CHAPTER SEVEN The Good Angel, the Bad Devil, the Smiling Man's Voice and Mother-God
• CHAPTER EIGHT The pugilist, Mary, and the mother with the fiery halo
• CHAPTER NINE Two rats and the extraterrestrial
• CHAPTER TEN The ghost in the history
• CHAPTER ELEVEN Stalemate
• CHAPTER TWELVE Maya, Little, and the world of illusion
• CHAPTER THIRTEEN Death, Egyptian style
• CHAPTER FOURTEEN Nobody
• CHAPTER FIFTEEN The voice didn't win
• CHAPTER SIXTEEN The world class artist of the symbolic world: the Mafia, the movie stars and the "Unconscious God"
• CHAPTER SEVENTEEN Can anyone that evil ever really die?
• CHAPTER EIGHTEEN The cheerleader
• CHAPTER NINETEEN Thoughts, lessons and conclusions
• APPENDIX 1 Long-term studies on schizophrenia
• APPENDIX 2 Brief review of psychoanalytic perspectives on schizophrenia
• REFERENCES