Psychotherapy for People Diagnosed with Schizophrenia

Specific techniques

Andrew Lotterman

• Publisher: Routledge
• Year: 2015
• Print ISBN: 9780415690447
• eBook ISBN: 9781317540953
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

In this unique book, Andrew Lotterman describes a creative approach to the psychotherapy of people diagnosed with schizophrenia and other forms of psychosis. Lotterman focuses on specific techniques that can be used in psychological therapy with people who have symptoms such as hallucinations, delusions, paranoia, ideas of reference, looseness of association and pressured speech. Formerly titled Specific Techniques for the Psychotherapy of Schizophrenic Patients, this edition updates research on the biology and psychology of psychosis and explores the many controversial issues surrounding diagnosis. It also includes two new chapters on the psychology and treatment of paranoia and on the experience of having a shattered self and the delusion of being the Messiah.

Lotterman's innovative approach aims to help patients with one of the most debilitating symptoms of psychosis: the collapse of language use. By restoring language as a way of communicating the patient's meaningful inner life to himself and to others, the patient is then able to undertake a more traditional form of verbal psychotherapy. The book presents detailed case histories of patients who have benefited from this method, highlighting the specific techniques used and the psychological improvements that followed. The approach presented here complements medication-based treatments that have only had partial success, as well as other psychological approaches such as cognitive behavioural therapy, family therapy and social skills training.

Psychotherapy for People Diagnosed with Schizophrenia will be a valuable text for clinicians working with people suffering from psychosis, including psychotherapists, psychoanalysts, psychologists, physicians and social workers. It will also be of great interest to academics and students.

1

INTRODUCTION

The roles of biology and psychology in people diagnosed with schizophrenia

The scope of the clinical problem

People given a diagnosis of schizophrenia often suffer from intense agony and loneliness. They may endure cruel emotional pain, and must bear up under tormenting feelings of humiliation, emptiness and despair. Efforts to understand and treat what is labelled “schizophrenia” have drawn from an array of medical specialties: neurology, neurobiology, biochemistry, radiology, physiology, genetics, epidemiology and infectious disease, not to mention psychiatry, learning theory and academic and psychodynamic psychology. Unfortunately, these have had limited clinical benefits, as I will outline below. The field of schizophrenia research is as fragmented as it is crowded. What complicates matters further is that there is probably no single entity of “schizophrenia” but rather a heterogenous group of conditions with varying etiologies and outcomes which are grouped under that term.

The emotional toll and social and economic costs of conditions called schizophrenia are enormous. For example, in the United States alone, it affects about 1.1% of the population, about 2.5 million Americans. The human cost is immense. Patients experience debilitating symptoms such as hallucinations, delusions, paranoid ideas, cognitive disorganization, social withdrawal, apathy and emotional flattening. The experience of self is often distorted. Patients feel themselves to be fragmented and helpless. Family and friends lose emotionally meaningful contact with psychotic loved ones and suffer along with the identified patient. Opportunities for emotional, creative and social fulfilment are shattered. The social and economic costs are also profound. As of 2002, in the US alone, the direct and indirect economic costs were estimated to be 62.7 billion dollars per year (McEvoy, 2007), and it is reasonable to assume that today that cost is much higher. Because people diagnosed with schizophrenia become ill when they are young, and can remain so for many years, the burden of illness is particularly severe. In the US approximately 12% of people diagnosed with schizophrenia are homeless, living in shelters or in prison. Another 16% are confined to chronic care hospitals or nursing homes (Torrey, 2006).

The purpose of this book

The reason for writing this book is to address a particular problem in the treatment of people diagnosed with schizophrenia. As I will outline, in recent times treatment has consisted mainly of biological interventions, mainly medication. As I will show, there is evidence that psychology can play an important role in both the etiology and the treatment of schizophrenic conditions. There is a group of people labelled schizophrenic who can benefit from the traditional forms of verbal psychodynamic psychotherapy (Rosenbaum et al., 2012; Pankey and Hayes, 2003). There is, however, another group of patients. These are patients who have symptoms of thought disorder, profound interpersonal deficits and poor self-object boundaries. They block out vast portions of their psychic life with primitive denial and projection, which in turn compromises their ego functioning. Their capacity to use words to describe their inner states is severely compromised. For this group, standard psychodynamic techniques may need to be modified to address the particular psychological structure of this form of psychosis, especially the disturbance in verbal function. Because standard psychotherapy depends on intact concept and language use, it is understandable that standard technique will break down in the face of disorders of thought and speech. A psychotherapy designed to address the particular psychotic psychological structure found in severe psychosis may be needed for these patients. The techniques described in this book are intended to describe this kind of psychotherapy.

The clinical limitations of medication

The foundation of treatment for schizophrenia in the last sixty years has been the use of antipsychotic medication. However, despite efforts to find effective treatments, the usefulness of antipsychotic drugs has been limited. Gutierrez (1997) reported that 20–30% of patients do not respond to these medications. Khan et al. (2001) found that there was less than 20% improvement in patients with positive symptoms when taking antipsychotic medication. Essock (1996) found that 48% of patients who were taking medication relapsed in the first year. Wunderinkk et al. (2013) found that dose reductions or discontinuation of antipsychotics during remission were actually associated with better long-term outcomes.

Certain symptoms are more likely to respond to antipsychotic medicine than others. Positive symptoms such as hallucinations, delusions and paranoid ideas are more likely to improve. However, negative symptoms such as social withdrawal, apathy, loss of motivation and emotional blunting remain uninfluenced by the use of medication. The Schizophrenia Patient Outcome Research Team study concluded: “There is no evidence that first or second generation anti-psychotics are effective for primary negative symptoms” (Lehman et al., 2004: 206). Moreover, even when antipsychotic medications are effective, patients stop taking their pills. Weiden (1997) found that 50% of patients had stopped medication after one year, and 75% after two years. The CATIE (Clinical Antipsychotic Trials for Intervention Effectiveness) study (2005) reported that 64–82% of patients were not taking prescribed medication after one and a half years.

The problem of non-compliance leads us to a bit of a paradox. If we take the position that schizophrenia is a biological condition and that medication is the only effective treatment for psychosis, then we are faced with a dilemma. There is no medication that will induce a psychotic patient to take his medication if he refuses to take medication.

Accounting for medication non-compliance and incomplete efficacy, only 10–20% of patients are being effectively treated with medication at the end of two years. For 80–90% of our patients then, we must look for some kind of psychosocial approach to help them with their illness. In terms of adherence to psychopharmacological treatment, if it is indicated, a trusting emotional connection with a therapist can play a central role in the patient’s choice to take medication.

Uncertain etiology hampers treatment

To effectively treat patients diagnosed with schizophrenia, it would greatly help to have some idea about what causes their problems. Unfortunately, there is no clearcut answer to this question. Whenever attention shifts to one etiologic focus, whether it is neuroanatomical, biochemical, neurodevelopmental, social or psychological, each new lead disappoints our hopes of finding a comprehensive cause. Each fresh discovery seems to apply only to some patients diagnosed with schizophrenia.

Uncertain diagnostic boundaries

Despite our attempts at understanding, the group of persons often given the diagnosis of schizophrenia remains confusingly heterogeneous. Over the years, we have tried to find that singular feature of the disorder that defines what is unique and characteristic of this group: premorbid functioning, age of onset, predisposing conditions, precipitating events, symptom clusters, duration of psychosis, cognitive and social impairment, neuroanatomical and neurophysiological markers, response to biological and psychological therapies, social and work functioning, and long-term outcome. No matter how narrow the criteria for diagnosis, and how rigorously we apply them, the response to therapy and the course of these patients’ problems seem to defy reliable prediction (Hawk et al., 1975). We have great difficulty agreeing with one another about who we should diagnose as suffering from schizophrenia, and how we should treat them. This is discussed further in the next chapter.

A degree of consensus about the conditions labelled “schizophrenia”

Many researchers and clinicians believe that the condition we label “schizophrenia” actually represents a heterogeneous group of disorders with a variety of etiologies and clinical presentations. Some of these conditions seem to spring from more biological dysfunctions, and some from environmental and psychological traumas.

Granting that there is probably no single unitary entity we can call “schizophrenia”, there seem to be some basic observations concerning non-affective psychosis about which there is a degree of agreement among many recent researchers. Here is a selected list (some of the following is based on a paper by MacDonald and Schulz, 2009). In what follows, I will put the term “schizophrenia” in quotes to underscore the controversies concerning its status as a unitary, reliable and valid diagnostic entity.

1. “Schizophrenia” manifests itself in a variety of symptoms, none of which reliably define it. Patients may have a few or many of the following symptoms, grouped into two clusters: “positive” symptoms such as auditory hallucinations, visual hallucinations, delusions, paranoid ideas, disorganized speech and ideas of reference; and “negative” symptoms such as social withdrawal, apathy, flat or absent emotional responses and occupational or self-care difficulties.

2. The first symptoms of “schizophrenia” usually begin in late adolescence or early adulthood.

3. The vulnerability to “schizophrenia” seems to be at least partially heritable. The concordance rate for monozygotic twins is about 45% (Cannon et al., 1998).

4. Medications that reduce psychotic symptoms block dopamine D2-like receptors (among others) but these medications are not equally effective for all “schizophrenic” symptoms (Swerdlow, 2011).

5. There is evidence that certain gene regions are associated with the development of “schizophrenia” in some patients. (e.g. 8p and 22q, DISC1, Dysbindin, Neuregulin and G72) (Lewis et al., 2003; Badner and Gershon, 2002; Craddock et al., 2006; Papaleo and Weinberger, 2011). However, a direct link between “schizophrenia” and a specific gene or a constellation of genes has not been established.

6. Certain environmental, nonhereditary factors also increase the risk of “schizophrenia”. These include: migrant status, age of the father, maternal exposure to famine during gestation, exposure to viral, bacterial and parasitic infection during gestation, maternal cannabis use, obstetrical problems and growing up in an urban environment. There is evidence from other research¹ that early childhood trauma may also play a role (Read and Ross, 2003) as well as early family environment (Tienari 1991) and trauma in adulthood (Hamner, 2000).

7. A variety of psychosocial treatments such as cognitive behavioural therapy, social skills training, family therapy and cognitive training have been found to be effective in reducing some symptoms (MacDonald and Schulz, 2009).

8. There are volumetric and/or morphometric abnormalities in multiple brain areas in some patients diagnosed with “schizophrenia” (Levitt et al., 2010). The affected areas include the hippocampus, amygdala and anterior cingulate cortex (Boos et al., 2007; Pantelis et al., 2009; Ho and Magnotta, 2010). These abnormalities include the size or shapes of cells, numbers of neurons, neurotransmitter receptors, neural circuits and abnormalities of cellular proteins. However, these morphologic changes are found in some patients but not others. Moreover, it is not clear whether the symptoms of “schizophrenia” result from these “primary” lesions (e.g. the loss of a critical neural structure) or the “secondary” effects of these abnormalities on other areas of brain function. In addition, the same abnormalities have been found in relatives with...

Table of contents

• Cover
• Half Title
• The International Society for Psychological and Social Approaches to Psychosis Book Series
• Title Page
• Copyright Page
• Table of Contents
• Foreword by Brian Martindale
• Preface
• Acknowledgements
• 1 Introduction: the roles of biology and psychology in people diagnosed with schizophrenia
• 2 Diagnosis
• 3 Structuring the treatment
• 4 The psychological therapy of patients diagnosed with schizophrenia
• 5 Techniques in specific clinical situations
• 6 Mental processes in people diagnosed with schizophrenia
• 7 Outcome
• 8 Paranoia
• 9 Two clinical syndromes: the shattered self and the wish to be a Messiah
• 10 Comparison with other techniques
• Appendix: patient sample
• Index