Foundations Of Contextual Therapy:..Collected Papers Of Ivan

Collected Papers Boszormenyi-Nagy

Ivan Boszormenyi-Nagy

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317772781
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

First published in 1987. These Collected Papers, covering a period of almost 30 years, will allow the reader to trace the developing thought of one of the world's seminal family therapists and theoreticians.

1

Correlations Between Mental Illness and Intracellular Metabolism

This paper summarizes the rationale of my years of research on red cell metabolism in schizophrenia. The crucial personality parameter pertaining to psychosis is seen in one’s capacity to utilize earlier identifications in approaching new people. The hypothesis then assumed that whether or not it is genetically determined, the biological substrate of such a relational capacity should be correctable with the intracellular metabolism of the brain or perhaps of all body cells. This hypothesis was underlying the study of phosphorus metabolism in red blood cells (Boszormenyi-Nagy, 1955; with Gerty, 1955; with Gerty & Kueber, 1956).

References

Boszormenyi-Nagy, I. Formation of phosphopyruvate from phosglycerate in hemolyzed human ethrocytes. Journal of Biological Chemistry, 212(1), 495–499, 1955.

Boszormenyi-Nagy, I., & Gerty, F. J. Diagnostic aspects of a study of intracellular phosphorylations in schizophrenia. American Journal of Psychiatry, 112(1), 11–17, 1955.

Boszormenyi-Nagy, I., Gerty, F. J., & Kueber, J. Correlation between an anomoly of the intracellular metabolism of adenosine nucleotides and schizophrenia. Journal of Nervous and Mental Disease, 124(4), 413–416, 1956.

It appears that there is an increasing realization of a need for a thorough reconsideration of our psychiatric nosological framework. The psychiatric thinking of the last few decades has shifted the focus of attention away from the medical frame of reference. This has been especially apparent in the United States, where some of the important contributions to the cultural and social applications of psychiatry have been made. This paper is intended to examine the implications of biological studies in general, and of intracellular metabolism in particular, for psychiatric nosology, especially in view of the mentioned shift of emphasis in our thinking.

What is the cause of this change in psychiatric thinking? Does the shift of emphasis toward cultural and social factors mean a new and better understanding of etiology, or does it represent only a swing of the pendulum toward a preference for theories on spiritual factors of causation?

It is impossible to answer this question without the clarification of our fundamental attitude toward the causation of what are called psychiatric conditions or illnesses. Most of us will probably agree that, in the majority of psychotic pictures, the question about bodily and environmental causal factors is not an either-or proposition. Instead, the correct question should sound: How much of the determination comes from either of these two areas? After consideration of the available amount of information regarding psychosis, we have to conclude that it has not been proven that in a phenomenon as complex as mental disturbance either inherited constitution or human environment could be completely excluded as a possible etiological factor. It is clear that human behavior is, to a great extent, determined by the hereditary traits of both species and individual.

Although it is impossible to describe the hereditary determinants of our behavior in detail, the whole of these traits may be viewed as an inborn strength or capacity for survival. It can be assumed that each of us presents a certain amount of this potential “strength” toward our social environment at the beginning of our interpersonal functioning.

It is also obvious that such an inborn “strength” has to be based on a certain kind of efficiency of the organism in general, and of its structures responsible for the organization of its behavior in particular. Theoretically, it should be possible to assign to each newborn child a single value expressing its strength for the complex task of successful human adjustment. Such a measurable property would be expected to give a Gauss-curve shaped distribution in populations. Yet, even the knowledge of this hypothetical value would not be sufficient for us to predict the actual extent of future adjustment in a given individual. Very few among us would doubt that there are significant differences as to the extent to which human environment can support or inhibit the process of personality development. Only a combined knowledge of the extents of both inherited flexibility of the organism, and of the total influence of its environment, would enable us to predict the actual level of healthy mental functioning in a given individual.

Consequently, other, more concrete questions can be asked. What is the physical mechanism of this constitutional disposition or of the bodily determinants of behavior? Since the subject of the question is in the biological frame or reference only, the answer is relatively easy. The inherent properties of the germinative cells determine the range of potentialities of the inherited characteristics of the individual. Such potentialities pertain to size, shape, color, the relative inferiority of organs, intelligence, etc. The mechanism by which these determinations are implemented must be part of the complex chemical operations of resting and dividing cells. In this sense, in each individual, the various kinds of tissue cells “inherit” certain patterns of metabolism, which eventually will determine the efficiency of the function expected from the corresponding tissue.

Some individual, for instance, may inherit a circulatory system of less than average resistance, another an immunity to certain infections, etc. In certain instances, a generalized constitutional metabolic deficiency of all cells of the organism might be manifested as a disturbance in the function of one of the organs or tissues. An example of this could be the phenylpyruvic disease in which, apparently, a generalized enzymatic failure manifests itself as a “behavioral” condition: oligophrenia. It is logical to assume that, although the enzymatic abnormality is generalized, it is the cells of the brain that have the lowest resistance to this interference.

The next question will pertain to the relationship between two sets of occurrences: the one of publicly observable data, and the other, the field of inner experience. Namely, if the implementation of hereditary traits of behavior rests ultimately on the cellular-biochemical level, we have to assume that there are certain fundamental determinants of behavior in the “psychological” frame of reference which correspond to these biological traits. In other words, what are those inborn fundamental behavioral patterns, characteristic of an individual, which would be discernible in spite of modifying effects of any possible environment? Or, in what manner would a given individual handle life experience differendy from others in the theoretical case of all having an exactly identical environmental history? We know of the existence of such fundamental genetically determined behavioral variables in the case of the above-mentioned phenylpyruvic disease. There, intelligence is affected as a result of a generalized enzymatic deficiency concerning the metabolism of aromatic amino acids. We know, on the other hand, that in schizophrenia it is not the intelligence function which is responsible for the behavioral disturbance. The crucial problem of these patients appears to be a less efficient or less flexible interaction with people, especially in emotionally meaningful relationships.

The next question is, can we conceive of a specific personality parameter, pertaining to psychosis, which is as fundamental a characteristic as for instance, intracellular enzymatic properties are fundamental to the organism? Although the answer to the last question, at the present time, most likely is negative, certain hypotheses can be formed. We know that the environment contributes to the formation of the ego or of the representation of the self in a human individual by two main ways. One is by providing the very facts of existence which the individual has to learn, whereas the other way is by providing models in the process of maturation, with which to identify. The classical example of above is the role of the mother who is the first catalyst of human interaction potentials, as well as the first model object for identification. Later on, the other significant adults play similar roles for the child. At a certain phase of development, the internal representations of outside people will not only provide us with “readymade” learned patterns of behavior, but they give content to our own self. Only after this has taken place can we deal satisfactorily with complex human situations, helped thus by our capacity to identify with the very roles played by ourselves, as well as the ones played by others. In this sense the extent of our capacity to utilize earlier identifications in approaching new people, determines the efficiency of our dealings with human situations or, of our interpersonal flexibility.

It is suggested here that impairment of the latter capacity of the human mind is the pertinent factor in “emotional illness” or psychosis. This potential or capacity has to have its mechanism in the brain just as operative intelligence has its own. Such mechanism ought to be dependent on the integrity of the structure and function of the brain. The functioning of the brain, on the other hand, as that of any organ, is dependent on various energy-producing intracellular metabolic patterns. Some of these patterns might be hereditarily vulnerable in the brain or in every cell of certain organisms. Such a deviation might conceivably be identical with a postulated “constitutional factor” in emotional illness in general, or schizophrenia in particular.

Our project at the Eastern Pennsylvania Psychiatric Institute endeavors to establish the descriptive criteria of fundamental interpersonal patterns by long-term observation of acute schizophrenic patients who are in intensive psychotherapy. Consecutively, the possibility will be tested whether some of the fundamental interpersonal patterns will correlate with patterns observed in the intracellular metabolism of the red cells of certain schizophrenic patients. At the same time, we realize a great need for a systematic comparison of various biological findings of different centers around the world for the study of the intercorrelations of these parameters, either on the same clinical material or with the help of more careful clinical description of the pertinent patient material, of the various studies.

2

Hospital Organization and Family-Oriented Psychotherapy of Schizophrenia

[This paper was written with James L Framo, Ph.D.]

This paper, first presented at the Third World Congress in Montreal in 1961, encompasses the early phases of conceptualizations as they grew out of family-based work with inpatients at the Department of Family Psychiatry of Eastern Pennsylvania Psychiatric Institute. The search for hypotheses concerning the effectiveness of the family-based approach extends into object-relations theory.

Regarding the phenomenon of transference, family therapy is described as a new perspective for the direct observation of some of the relationship patterns that in individual therapy or analysis are able to be inferred only from reenactments of early family relational attitudes between patient and therapist. This observation is expanded to the exploration of the dynamics of hospitalization. It is, therefore, hypothesized that behavior toward the hospital staff and other patients may replicate familial patterns of relationships.

Since the various family members share their regressive tendencies toward continuing to relate to their internal objects through alleged relating to real others, their, often painful yet strong, need-complementarity leads to a form of stagnation that prohibits separation and mature individuation. Their resistance to change may be so violent that other family members may take on paranoid or otherwise psychoticlike attitudes.

Another combination of “family transference” with internal object relations was described in this paper. In her delusional world a psychotic was observed to remain in the company of the endopsychic representations of regressively gratifying early relationships. Consequently, the patient may displace (transfer) onto the persons in the hospital environment not only these early familial images but the interactions among internal objects as well. Therefore, whole family climates can be transferred upon unsuspecting others, often instantaneously. Naturally, the shifts of family transference onto strangers did create significant conflicting “loyalties,” a term first used in this paper.

All of the complex relational phenomena of hospitalizations were elicited and made further observable through the introduction of family day activities, partial care of the patient by her mother, multiple family therapy groups with their combined familial group dynamic processes and many others.

This paper has evolved from our work on a research treatment unit, where attention has been given to the interaction of three major therapeutic factors: intensive individual psychotherapy, family therapy, and ward milieu therapy. The organizational design of this project is based on an assumption that the most pertinent focus of schizophrenic psychopathology is the dimension of relatedness. Most of the workers who have conducted intensive psychotherapy of the schizophrenic conditions agree on the supporting and egoconstructive influence that good relationships can have upon the “weak” ego of the schizophrenic (Federn, Sullivan, Fromm-Reichman, Eissler, Sechehaye, Rosen). The same principle is implicit even more specifically in the work of the pioneers of the family-based treatment of schizophrenia (Lidz, Bowen, Wynne, Jackson). Moreover, the entire therapeutic effect of the psychodynamically oriented psychiatric hospitalization is also translatable into a relationship psychology. In this way we strongly contrast psychiatric hospitalization with the service-based therapeutic concept of the general hospital. In other words, in general medicine or surgery, the patient is helped by specific acts being done to him, whereas in the psychiatric hospital help largely consists of furthering the capacity of the patient to utilize human relationships. Thus, the emphasis in psychiatric hospital treatment shifts strongly from what is being done towards by whom it is done and in what manner.

Thus far we have stated those theoretical foundations of our paper that do not appear new or controversial to the expert student of psychotherapy with schizophrenic patients. The specific main point of view of this presentation, however, may not be readily acceptable to those workers who have not shared our several years’ experience with the family treatment of schizophrenia and have not familiarized themselves with publications of workers in this field. We feel, specifically, that the study of the psychopathology of schizophrenic family interaction can develop into one of the basic sciences for hospital psychiatry. For one thing, the bizarre symptomatic behaviour of the schizophrenic patient in the hospital can often be decoded as a repetitious meaningful message within the context of family living. When the patient enters the psychiatric hospital the uniform and routine aspects of her first contacts leave her with a feeling of isolation and loss of meaningful human relationships; she then has to recreate a living space of relationships and can only fall back on past experiences and fantasies. Just as in the psychoanalytic situation the patient is forced to respond with early infantile patterns because of the frustrating, one-sided nature of the relationship, similarly, certain facets of psychiatric hospitalization (such as its perceived impersonalness) foster “transference” of the patient’s attitudes from the family to hospital personnel. The study and utilization of these unconscious, reconstructive patterns has been the purpose of the organization of our research hospital unit and of this present report on its activities. We do not intend to give here a detailed report on the psychology of families of schizophrenic patients; rather, we will use the dynamics of these family situations in order to introduce a framework for the philosophy of a therapeutic approach.

Before getting into the specifics of our findings it would be apropos at this point to describe the nature of the situation from whence our observations have been derived. Our observations originate from a special psychotherapy unit of the Eastern Pennsylvania Psychiatric Institute. The unit was organized four years ago, for the purpose of obtaining a better understanding of schizophrenic psychopathology and learning more effective methods of treatment. The project has had as its bias psychological methods of treatment, particularly intensive psychotherapy. From its inception, furthermore, relatives have been involved in the treatment as well as ward personnel. The therapeutic staff consists of two full-time and three half-time psychiatrists, two psychologists, and a social worker. Inasmuch as the unit consists of 20 beds, there is intensive individual and family therapy coverage, and sufficient time for the staff to have frequent conferences for the exchange of observations. It should be added that a large proportion of our patients would be described as “hard core,” chronic schizophrenic cases.

Each patient receives individual psychotherapy at least three times a week. Daily group meetings are held with all the patients, nurses, and ward administrator in order to foster communications on the group level, where the most important transference reactions so often take place unnoticed. We have established a variety of ways of stimulating emotionally meaningful relationships. For instance, once a week the community meetings include the therapists as well—and a family-conference-like quality is further emphasized by the reading of a report by one of the nurses on one or two patients’ recent behaviour. These reports consist of confronting statements about the patient; they state, in effect, “this is what you have been doing; this is how others see you.” The patients then have an opportunity to respond to these reports (which are sometimes critical) in the presence of the other patients and staff. Opinions frequently are divergent as the patient may dispute the report, and this situation frequently stimulates family transference and countertransference reactions. Powerful reality-testing tools are brought to bear when the therapist can point out that something the patient resists “seeing” is seen so clearly by others. It is rare that other patients will side with the staff, but occasionally this happens, and then sibling...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• Introduction
• Acknowledgments
• 1. Correlations Between Mental Illness and Intracellular Metabolism
• 2. Hospital Organization and Family-Oriented Psychotherapy of Schizophrenia
• 3. The Concept of Schizophrenia from the Perspective of Family Treatment
• 4. The Concept of Change in Conjoint Family Therapy
• 5. From Family Therapy to a Psychology of Relationships: Fictions of the Individual and Fictions of the Family
• 6. Relational Modes and Meaning
• 7. Loyalty Implications of the Transference Model in Psychotherapy
• 8. How I Became a Family Therapist
• 9. Ethical and Practical Implications of Intergenerational Family Therapy
• 10. Behavioral Change Through Family Change
• 11. Comments on Helm Stierlin’s “Hitler as the Bound Delegate of His Mother” in History of Childhood Quarterly
• 12. Clinical and Legal Issues in the Family Therapy Record
• 13. Contextual Therapy: Therapeutic Leverages in Mobilizing Trust
• 14. Trust-Based Therapy: A Contextual Approach
• 15. Contextual Therapy: The Realm of the Individual (Interview with Margaret Markham)
• 16. The Contextual Approach to Psychotherapy: Premises and Implications
• 17. Commentary: Transgenerational Solidarity—Therapy’s Mandate and Ethics
• 18. Transgenerational Solidarity: The Expanding Context of Therapy and Prevention
• 19. Contextual Therapy and the Unity of Therapies
• Index