Psychotherapeutic Approaches to Schizophrenic Psychoses

Past, Present and Future

Yrjö O. Alanen, Manuel González de Chávez, Ann-Louise S. Silver, Brian Martindale, Yrjö O. Alanen, Manuel González de Chávez, Ann-Louise S. Silver, Brian Martindale

• Publisher: Routledge
• Year: 2009
• Print ISBN: 9780415440127
• eBook ISBN: 9781134070107
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Highly Commended in the Psychiatry category at the 2010 BMA Medical Book Awards!

Psychotherapeutic Approaches to Schizophrenic Psychoses brings together professionals from around the world to provide an extensive overview of the treatment of schizophrenia and psychosis.

Divided into three parts – past, present and future – the book begins by examining the history of the treatment of schizophrenia and psychosis, with reference to Freud, Jung, Harry Stack Sullivan and Adolf Meyer, amongst others.

Part two then takes a geographical look at treatment and its evolution in different parts of the world including the UK, USA, Northern Europe and Eastern Asia.

Finally, part three covers the range of interventions, from pharmacological treatments to psychoanalytic psychotherapy to CBT, with the aim of helping to shape the future integration of treatment.

With contributions from leading figures in the field, this book will provide a varied examination of treatment, and spark much-needed debate about its future. As such it will be essential reading for all mental health professionals, in particular those involved in psychiatry, psychology and psychotherapy.

Part I
The past

Early history of the treatment of schizophrenic psychoses and the pioneers of the psychotherapeutic approach

Chapter 1
Can we approach patients with schizophrenic psychoses from a psychological basis?

Yrjö O.Alanen

The schism between ‘understanding’ and ‘explanatory’ psychology

The diagnostic boundaries for schizophrenia have never remained fixed. Their criteria have been different at different times, in different countries and in different psychiatric cultures. The clinical heterogeneity of schizophrenic patients makes us ask whether it is even justifiable to speak about an illness called ‘schizophrenia’. Such diagnostic practice certainly has disadvantages for both research, where notably dissimilar patients are placed into the same diagnostic clusters, and for individuals, who continue too often to carry the diagnostic label even after their recovery. Eugen Bleuler (1911), the originator of the name ‘schizophrenia’, himself concluded that schizophrenia is not a uniform disorder but rather a group of disorders including ‘a nuclear group’ with well-known clinical subgroups and ‘a borderline group’ difficult to distinguish from neuroses and manicdepressive psychoses. In line with him, we should at least prefer the term ‘the group of schizophrenic psychoses’.

In the study of etiological factors as well as in treatment, the heterogeneity of schizophrenic psychoses should be taken into account much more than is usually done today, including the patients’ individual psychological characteristics and life situations.

Can schizophrenia be approached via psychological understanding, or is it a disorder exclusively due to biological factors? The controversy that leads to questions of this kind has a long history with many cultural implications (see Chapter 2).

An influential statement on this topic was made by the German psychiatrist and philosopher Karl Jaspers (1913/1949), who introduced the concepts of ‘explanatory’ and ‘understanding’ psychology in the early twentieth century. The former concept referred to disorders explained by organic brain pathology, while the latter pertained to mental conditions regarded as psychologically understandable. Jaspers was inclined to place schizophrenia in the category of explanatory psychology. This was the tradition cherished almost exclusively by academic psychiatrists in Europe during the twentieth century. It was already adopted by Emil Kraepelin, ‘the great classifier’, who in the 1890s regarded the disease he called ‘dementia praecox’ as a brain process of unknown causation, leading to demented end states.

Eugen Bleuler (1911) was influenced by the work of Freud and Jung (see Chapter 4). He noticed that the outcome of the disorder was not necessarily as inevitable as Kraepelin had taught. Still, Bleuler also described the basic or ‘primary’ symptoms of schizophrenic psychoses—autism and disintegration of cognitive and affective functions—as being most probably due to organic causes, but attributed the content of the ‘secondary symptoms’—including delusions and hallucinations—to the patient’s individual complexes. The primary symptoms of schizophrenia were later discussed and redefined in attempts to distinguish ‘real’ schizophrenias from more benign schizophreniform psychoses (e.g. Langfeldt, 1939; Schneider, 1929/1962). In European psychiatry, even the term ‘Praecox-Gefühl’ (‘praecox feeling’) was presented as a criterion of the diagnosis of schizophrenia. It referred to the examiner’s intuitive experience of being unable to establish any empathic understanding with the patient.

In the USA, such pioneers as Adolf Meyer (1906, 1910), Harry Stack Sullivan (1931, 1962) and Frieda Fromm-Reichmann (1959) made the tradition more favourable for an approach to schizophrenic psychoses based on understanding psychology (see Chapters 6 and 7). Following this tradition, the understanding of schizophrenic patients developed. However, the belief that schizophrenia is an organic disease and should be treated as such became dominant even in the USA, especially during the 1990s, called ‘the decade of the brain’. However, we should still not forget the words written by Meyer almost one hundred years ago:

The comfort of working under the cover of fatalistic and analyzed conceptions of heredity, degeneracy, and mysterious brain diseases… is a powerful and unconsciously cherished protection… We are, I believe, justified in directing our attention to factors we see at work in the life history of the cases of so-called dementia praecox.

(Meyer, 1910, his italics)

The contradiction between the American and European concepts of schizophrenia some decades ago was most clearly illustrated by the results of the well-known British-American collaborative research project (Cooper et al., 1972), which showed ‘schizophrenia in London to be quite different from schizophrenia in New York’. This result could probably be interpreted from the standpoint of the different developments in the ‘understanding psychology’. In the USA, psychiatrists were more inclined to view schizophrenic psychoses as understandable. They also found similar (though less pronounced) psychodynamic characteristics in patients now most often diagnosed as ‘schizotypal’ or ‘borderline’ personality disorders. Parallel to this, the American concept of schizophrenia gradually expanded. In the UK, the dominant opinion was that schizophrenia is psychologically nonunderstandable and the enlargement of the category of ‘understandable disorders’ narrowed down the concept of schizophrenia.

This, and other corresponding studies, led to a resumption of the Kraepelinian symptom-based classification, as manifest in the diagnostic and statistical manuals (DSM) compiled by the American Psychiatric Association (fourth edition, 1994). From the point of view of epidemiological research, this was necessary, but we should bear in mind that the planning of treatment also requires different approaches.

Some therapists have been inclined to completely deny schizophrenia being an illness and have rather spoken of a person’s desperate attempt to protect himself or herself in an anxiety-provoking environment that threatens to destroy individuality (e.g. Laing and Esterson, 1964). However true this may be, one must acknowledge the huge regression of psychological functions and loss of social abilities experienced in such autistic decline.

How can we understand the schizophrenic person?

Sigmund Freud’s essay on the autobiography of Dr Daniel Paul Schreber, the eminent lawyer who experienced schizophrenic psychosis, was the first in-depth account of the inner psychology of a schizophrenic person (Freud, 1911c; see Chapter 3). Freud distinguished two phases in the psychodynamic development of Schreber’s psychosis: first a loss of differentiation of personality functions, including regression to early narcissism with abandonment of object relations; then attempts to find restitutional solutions, which were peculiar but still psychologically relevant. These basic interpretations have been confirmed by numerous psychoanalysts working with schizophrenic patients.

Why is such understanding still so difficult to adopt, even for psychiatrists and other mental health workers? A number of factors nurturing such antagonism can be listed:

• The commitment of medical research and education to the natural sciences tradition makes it difficult to appreciate work representing different theoretical outlooks.

• The expansion of brain research seemed to give support to the belief that schizophrenia is an organic disorder unrelated to psychological factors.

• The major influence of the pharmaceutical industry.

• The belief that psychotherapeutic work with psychotic patients could not possibly be widely applied in public health care because of the extensive staff resources that would be needed.

• The results of rigidly planned controlled psychotherapy trials have not been promising.

• Freud’s belief in the irreversible nature of the narcissistic regression has engendered a pessimistic attitude towards psychotherapeutic treatment of schizophrenic patients.

• Studies of the psychological etiological factors of schizophrenia arouse anxiety and resistance, especially when they are (erroneously) perceived as accusing parents for their child’s illness.

• Our defence mechanisms emphasize the difference between us and our patients, favouring superficial drug treatment, which helps us to avoid encountering the patients’ deep-rooted problems.

One point should be added connected with the ‘praecox feeling’ mentioned above. Many people, even professionals, really find their schizophrenic patients more difficult to understand than those suffering from neuroses or narcissistic disorders, and this is not only due to their own unconscious defence mechanisms. In order to understand the psychic functions of schizophrenic patients, therapists need, besides adequate training, a genuine interest in these patients, a good capacity for empathy and a good ability to access their own unconscious ‘psychotic domain’, as manifest in our dreams. These qualities will provide us with insight into the patient’s anxiety and regressive, concrete thinking that is still amenable to symbolic interpretation. Many psychiatrists and other professionals—even therapists—find this line hard to cross.

Based on schizophrenic patients’ regressive state and the nature of transference-countertransference experiences, psychoanalytic investigators have concluded that severe frustrations of gratifying experiences within the early mother-child relationship are the deep-lying source of schizophrenic psychoses. An empathic, ‘holding’ (Winnicott, 1960) way to relate with the patient may gradually open the possibility for new restoring growth of the personality within a reliable, ‘mirroring’, symbiotically oriented interrelationship. The development of psychoanalytically oriented psychotherapy with its different schools and modifications will be described in several chapters of this book.

However, some remarks should be added here. It is important to note that the ‘blame’ for early frustrations in the future patient’s life should not be placed on his or her mother’s shoulders. The innate inclinations of children, e.g. their pronounced autistic tendencies and low-level tolerance of anxiety, should also be taken into account here, and it should further be emphasized that the early mother-child relationship never develops in a vacuum. The nature of the mutual relationship between the mother and the father has an impact on it, as do the overall environmental circumstances. The parents’ own childhood experiences and development may also be crucially important. The author of this chapter has described the origin of schizophrenia as a multifactorial and multilayered process including both biological and psychosocial factors, which are weighted differently in different cases (Alanen, 1997). With regard to psychological predisposing factors, not only the crucial early human relationships but also the subsequent developmental phases and experiences have importance. Especially the two individuation-separation phases, the first in early childhood and the second in adolescence, may significantly increase the risk of psychosis or its avoidance.

The interaction between the individual’s genotype and the longer term family environment has been most clearly shown by the extensive and methodologically comprehensive adoption study by Pekka Tienari and his group (Tienari et al., 2003, 2004; Wahlberg et al., 2004; Wynne et al., 2006). They found that schizophrenia spectrum disorders (schizophrenic and paranoid psychoses and closely related personality disorders)¹ in adults were more common in those who had been adopted away from a mother with a schizophrenia group illness than among the control adoptees. But a crucial finding was that this only occurred at a statistically significant level when ...

Table of contents

• The International Society for the Psychological Treatments of Schizophrenias and other Psychoses book series
• Contents
• Figures and tables
• Contributors
• Foreword
• Introduction
• Part I The past
• Part II From past to present
• Part III From present to future
• Name index
• Subject index