The following is the text of Dr Steinman’s presentation at the ISPS (International Society for Psychological and Social Approaches to Psychosis) 15th annual meeting in Boston, MA, USA on October 16, 2016.
I believe that, in the right hands, an Intensive Psychotherapy of psychotic states can lead to healing and, often, a cure of a previously debilitating condition. By cure I mean the cessation of delusions and hallucinations as they are explored psychodynamically, and a gradual titration off of medication, with the cure lasting—even without continuing psychotherapy.
But these are old-line Intensive Psychotherapeutic views, out of synch with the current brain disease model of schizophrenia and the other psychoses. The field of psychiatry views schizophrenics as suffering from a brain disease but my view, over 45 years of out-patient psychiatric practice, is that most psychotic phenomena are comprehensible within the history of the person. Our therapeutic task is to engage our patients in order to try to illuminate their inner preoccupations and engage in a dynamic psychotherapy aimed at healing and a possible CURE of schizophrenia. Of course, biology plays a part in a patient’s disorganization, and some patients would rather take medication than take a serious look at how they became so disturbed, even if the field of psychiatry did offer much in the way of helping an upset person try to understand his or her psychosis—which it usually does not. But to only medicate and work on social skills is a disservice to patients.
What is required in the treatment of severely psychotic patients is to try to help them understand their own metaphor and symbolism contained in delusions and hallucinations; as cognition improves, medication can often be titrated down and frequently stopped. For some severely disturbed psychotic patients, as I have chronicled in Treating the ‘Untreatable’: Healing in the Realms of Madness,(1) and the more academic Self Psychology and Psychosis: the Development of the Self During the Intensive Psychotherapy of Schizophrenia and the other Psychoses(2), there is hope for healing and sometimes CURE via an intensive psychodynamic exploration. TREATING the ‘UNTREATABLE’ presents a dozen schizophrenic patients, successfully treated with an Intensive psychotherapy, along with a rationale and therapeutic principles for such a psychotherapeutic approach with schizophrenics.
With these profoundly distressed, yet creative and fascinating people, I inquire into the nature of severe distortions of reality and how the patient developed hallucinations, delusions and bizarre phenomena of thought and action. Most importantly, we look at the symbolic meaning of such phenomena, as well as the affective state when various psychotic distortions began. I also look to the origin in the patient’s mind of other persona, usually stuck in some early painful and traumatic series of events. As far as I am concerned a psychodynamic psychotherapy, making use of the concepts of unconscious motivation, resistance to change, transference and countertransference phenomena, and the benefit of interpretation of these occurrences is crucial in the psychotherapeutic treatment of schizophrenia and other psychoses.
In addition, just as there is meaning to dreams, there is symbolic meaning to the patient of his or her hallucinations and delusions, as if they are self-told fantasies and fairy tales; it is our job to help the patient understand his or her own metaphor and symbolism that have taken on the concretized form of psychotic delusions and hallucinations. I’m sure this is what we all do, all of us who aspire to a psychodynamic psychotherapy of schizophrenia and other forms of psychosis. I’m sure that we all try to ferret out the origin of all self-states, of disturbing ideas of reference, painful hallucinations, and delusions. Or at least that is what we all should try to do.
All too often, however, I find that disturbed people have been treated with more and more medication, with less and less of an attempt at elucidating how these states began. It’s not that current practitioners of psychiatry have evil intentions in the treatment of psychosis. It’s not that practitioners are unempathetic to the severely disturbed patients they see. It is much more the case that the field of psychiatry for the last 45 years or so has thought that schizophrenia is a brain disease with an organic and biological basis, Hence — the theory goes — those who suffer from schizophrenia need treatment with “antipsychotic” medication. Under the barrage of Big Pharma advertising and the academic psychiatric establishment having bought into the notion that there is nothing psychological in a psychotic person’s delusions or hallucinations, world-wide psychiatry has capitulated to the biologic and genetic origin school of thought of schizophrenia being a brain disease.
This is a simplistic view. A closer look at the origins of psychotic thinking in people who end up being diagnosed schizophrenic, or psychotic in some other fashion, is that these people are very upset. With anxiety, with intense terror, with withdrawal from the world, comes a cascade of thoughts and swirling neurochemicals that worsen the situation. Of course “antipsychotic” medication can be helpful to quell intense anxiety, but finding out the origin of disturbed beliefs is an all-important task of practitioners with an analytic or psychodynamic bent. Sometimes medication is helpful for that. But generally not as a lifetime treatment. All too often medication, which might help someone calm so that they can look at psychodynamic issues that have played a major part in the development of psychosis, becomes a treatment for life. Of course I use neuroleptic medication if necessary, but generally for a short period of time and at low doses. This use can be during a period of crisis, of intense anxiety or psychotic decompensation into delusional beliefs, alter personalities, hallucinations and bizarre thoughts and feelings. There are many cases that exemplify the type of work that I do; suffice it to say that a large percentage of my psychotic patients respond to psychodynamic exploration, often titrating down and stopping medication.
Let us keep in mind Bockoven and Solomon’s(4) AJP paper from the 1970’s that compared patient groups before the use of “antipsychotics” with those who took them. Those who took them had less initiative and motivation and a poorer prognosis. Nor should we forget Loren Mosher’s 20-year follow-up on patients who didn’t take “antipsychotic” medication; depending on the criteria used, 60-85% showed a good social recovery without drugs.(5) Harrow and Jobe,(6) in a 2007 article, found that a high percentage of patients who refused or stopped the drugs had a higher global level of functioning than those who took them.
If “antipsychotics” work — without causing metabolic syndrome, extreme weight gain, altered glucose and lipid metabolism, and other serious side effects — there may be no problem with their extended use. All too often, though, side-effects occur and patients either suffer them chronically or go off medications, never having learned to recognize and deal with their own inner demons, since understanding of the content and the origin of psychosis is rarely a part of psychiatric treatment.
In 2006, we held an ISPS meeting, Trauma and Psychosis(7), on the traumatic origin of psychosis in Santa Monica. Now, not every case of psychosis appears to have this kind of intense traumatic origin, but quite a number of them do. Certainly, over 45 years of practice I have had many patients who easily fit into that way of looking at psychosis.
Here is a case example of a CURE effected by the use of Intensive psychodynamic psychotherapy in a person repeatedly hospitalized and overly medicated by other psychiatrists for more than seven years. The illustration is similar to many others I have treated successfully and demonstrates how Intensive psychotherapy can heal and sometimes CURE schizophrenic patients. The vignette shows how painful external (and hence internal) events led to dissociation or withdrawal into a world of psychotic thought. Even though this patient had been heavily medicated, and in and out of psychiatric hospital settings repeatedly for more than seven years, psychotic thinking and symptoms ceased only when the origin of psychosis had been understood by the patient and myself, and worked through in the usual psychodynamic psychotherapeutic fashion.
Three Rats and the Extraterrestrial
Lois was a depressed, withdrawn woman in her mid-thirties when she consulted with me. She had a previous diagnosis of chronic paranoid schizophrenia, had been hospitalized several times, and had been treated for the previous seven years with high doses of “antipsychotic” medication. She had lived in a halfway house for the better part of a year, had had extensive daytime hospitalization and other supportive ancillary therapies and now lived alone in a rooming house. She was unkempt, disheveled, clearly preoccupied and hallucinating.
She had been married, but was now divorced. She had given up custody of her children, and had had a persistent delusion for years that three rats were gnawing away at her. She had little contact with anyone except for an old friend of hers who sent her to me. By everyone’s account — previous friends, family, psychiatrists and ancillary staff — she was a burnt-out case.
The diagnosis of chronic paranoid schizophrenia had been made during one of her first hospitalizations, when she told a psychiatrist about the three rats gnawing at her. In failing to help her try to fathom the meaning of three rats gnawing at her, he missed the opportunity to open a pathway to an understanding of Lois’ projected imagination.
People with delusions are beset by images and a concatenation of feelings that it is impossible for them to bear — at least to bear in their current vulnerable state. Hence the delusion; the projection outside of themselves of issues they can’t handle. Like Freud’s notion of the return of the repressed, having to do with issues one has put out of consciousness coming back to bedevil one, these people—perhaps due to a greater imaginative quality, perhaps a poorer synthetic ability, perhaps more pain and trauma in life—project issues outside of themselves.
Projected issues, however, are just that. Like a tethered rubber ball on a paddle, they keep coming back to where they began. The fearful, isolated, lonely paranoid gets the interest and involvement he or she craves, but to a much more heightened and intense extent than anyone could ever desire. In the delusion or hallucination, though, may lie a key to the code of the person’s thinking. Sometimes, it may take years to decipher the meaning of delusions; here it was much simpler and moved very quickly.
Lois presented herself as withdrawn, apathetic and quite noncommunicative. Luckily, her friend had brought in her hospital records. As I tried to get her to talk, I thumbed through the beginning of her copious chart and came across the chief complaint of her first hospitalization: three rats gnawing at her heart. This was the opening I needed, so I asked Lois: “Do three rats gnawing at you mean anything to you?” Needless to say, she hadn’t been asked that question by previous psychiatrists or even thought very much about the meaning of such a powerful image. As usual, since this was early in my years of treating people, I was dumbfounded that she hadn’t been asked about the meaning of her image; unfortunately, though, I was beginning to expect such a reply. What this said about our profession and the way most of us treat schizophrenics and delusional people, I was only beginning to suspect.
I always find it strange that a person can be totally immersed in a terrifying or otherwise very upsetting series of thoughts, or a delusion, and not think much about why they’re having such thoughts or be asked by their psychiatrist what the meaning to them is of such thoughts. How can one gain control over psychotic material if one can’t step back and understand it? How can patient or psychiatrist make sense of bizarre delusions if they never discuss their content and possible meaning?
If you ask the lay person what a psychologically-minded therapist does, he’ll say something like: “help people make sense of their dreams and life and fantasies; maybe, he’ll help the person make sense of the symbols of his creations.” But not so with psychosis. Here we are led to believe that brain disease trumps all and that it is impossible to ferret out the meaning of psychotic phenomena, helping a patient to calm and heal as internal material is understood. So, seven and a half years later, Lois was where she was when she first was hospitalized, in large part because her psychiatrists and other treaters had not engaged her and asked the questions that might have released her from her delusional bondage.
What did the three rats mean? She didn’t know. I had some sense immediately, for she had three children. When did the image begin? It was prior to the long (six month) hospitalization, after the birth of her youngest child, when she couldn’t bear to see her children, felt terribly guilty about being away from them, yet was unable to handle any interaction with them. Frustrated with the lack of any previous psychological treatment for Lois—and being a very young clinician—I quickly asked: “Could the number three relate to your three children, burrowing into you as your own feelings of loss and guilt about not being involved with your three children burrow into you?” She hadn’t thought about such a possibility.
This not having thought about it is a major part of the difficulty in a delusional person. If they did think about it, the meaning would most likely become clear, as did the meaning of the three rats. But the issues involved are, for whatever idiosyncratic reasons, too much. Such a person needs help to understand the meaning of his or her productions, the psychological mechanisms involved and, most of all, to deal with the underlying feelings that led to the formation of delusions. This is why it is essential that the treating psychiatrist or therapist attempt to help clarify the ramifications of illusions and delusions and hallucinations. To not do so, to diagnose and medicate alone, often leaves a patient without a channel to understanding him or herself.
She agreed that the rats might represent her three children gnawing at her feelings. She seemed comforted by this possibility, and much more willing to bring up historical and, — gradually, over a period of several months of twice a week psychotherapy — intra-psychic and emotional material that had persisted for many years. She was an only child of a critical and negative mother and a loving, indulgent father. Her father loved her unconditionally and served as a buffer against the constant jibes and denigrating comments of her mother. Her mother excoriated her; her father extolled her.
When she was seven, she and her father were told by her intimidating, extremely impressive old Russian ballet teacher that she “dances like she comes from another planet.” This served as the seed of a strong fantasy that she came from outer space. If she did come from outer space, this might account for her mother’s criticism and caustic comments. She was sheltered in her father’s love, because he too must come from outer space; her mother must be an earthling, jealous of her extraterrestrial origin. Such a belief comforted her, seeming innocuous enough, but laden with unforeseen difficulty.
When she was thirteen, her father died unexpectedly. She was grief-stricken and had to be hospitalized for a number of months. During those months she did the expected for someone who has broken the bounds of reality. She created not a fantasy, but a delusion, of her father always with her. She had never talked of this to anyone before, neither when hospitalized in her early teens nor during later hospitalizations and other periods of psychotherapy. She felt safe enough to tell me this, perhaps because she had been so frightened of the three rats which we had deciphered, perhaps because she felt we both could speak the same language — the language of understanding the meaning of her delusional imagery.
Since his death more than twenty years previously, her father had been by her side all her waking life. When she passed someone a cup of coffee, she passed him one too. When she went bicycling, he went along on his own bike. Whatever she did, she was accompanied by her much-loved father. He was kept healthy and whole in her delusional reality; as far as Lois was concerned, her father remained vibrant and alive, not mouldering and decaying in the ground.
Long days and nights, when she was apparently alone, were spent immersed in conversation and delight with her lost and protective father. She kept her delusion secret, probably because some part of her knew her father was dead and she didn’t want to disrupt her internal world with the harsh reality that included her continuously sniping and now depressed mother, and the fact that her father had died. She appeared to the world to be recovered from the serious decompensation that had led to her adolescent hospitalization, but internally she maintained a rich and vivid delusional life and constant activities with her father. Externally, Lois appeared to keep it together, enough so that she married in her late teens. In her early twenties, she went further into her comforting delusions of her father when her first husband hanged himself, for no apparent reason other than that he was having a “bad trip” on the psychedelic drugs he was taking at the time. Another sudden and unexpected death reinforced her retreat into delusional reality. Several years later she married a very understanding, solid man who looked after her until she decompensated in the postpartum period following the birth of their third child.
A delusional reality is both fragile and rigid. Patients cling to delusions tenaciously and, once having created delusions, have a propensity to become delusional in every which way. Lois had two very important losses which she attempted to deal with by creating the delusional reality of her comforting father. Now, with her breakdown in her thirties, she developed paranoid delusions that terrified her, in addition to the delusion of the rats gnawing away at her heart. What harm is there in the protective delusion of the father to help an adolescent cope with his death? The harm lies in the increasing propensity to develop all types of delusions, running the gamut from protective and playful to destructive and terrorizing. In the process one’s actual self gets buried under a layer of self-obfuscating phenomena contained within the delusion.
In the telling of her delusions and history, with a little prodding from me about how difficult it was to accept her father’s death, her mother’s neglect and abusiveness, and the other pains of life, she gave up her delusions in the following fashion. She recognized that the belief that she was an extraterrestrial was a way of seeming important and special, as she had seemed special to her ballet teacher, and definitely was special to her father. It was a way to protect her from her mother, and give importance to her existence. The delusion of her father being constantly with her evaporated over a period of about three months, aided by several few day hospitalizations to keep her from harming herself. This was a dangerous time for her, so I kept a very close watch over her, seeing her more frequently for a few weeks, trying to be alert to any potential suicidality; hence the short hospitalizations during this critical time.
To give up this delusion was risky. Not only was it comforting, but she had never mourned her father’s death twenty years earlier. In addition, the fused, psychotic delusional intensity meant that her father meant, if anything, more to her as a delusional figure than as a real and loving person. My experience with delusional people is that they are very creative. Consequently, I wasn’t surprised when Lois found the means to give up the long-held delusion of her father. This was accomplished by the development of a transitional, short term delusion of her three children constantly by her side. In short, she substituted her children for her father in delusion land. (Once open to delusion formation, there is no end to them until one becomes aware of what one is doing.
Rather than being an impediment, though, this new delusion was a flash of inspiration and a therapeutic aid. We were able to talk about her yearning for those she loved, whether father or estranged children. She used delusions as a way of believing she was in contact with loved ones, all the while feeling powerless to actually be in contact with loved ones. Delusions were seen as yearning for those she loved. I suggested that she try to make contact with her ex-husband and become a part of her children’s lives. With this change of focus toward the world, and an emphasis on the means of reconciling with her children—a definite possibility, as opposed to being in touch with her long dead father—the patient gave up all delusions and focused her considerable energy on her children. Without internal delusions taking up her loving vital energy, she was able to relate to her former husband and reestablish a very good and continuing relationship with her children. In addition, she became quite successful at two different careers, neither of which was ballet.
Her twenty-year-long delusional orientation dissolved over a six- to eight-month period. We had talked her language in such a way that her psychic energy could travel outward toward life, instead of incessantly cycling inwardly toward delusion, blockage and death. She finished therapy, over the next two years — off all “antipsychotic” medication — having more than achieved gains she had never dared to hope for. Over some years, she kept in touch by mail, apparently having maintained the gains of an exploratory psychotherapy of delusions, without resort to dramatic and delusional representations of feeling states.
More than thirty years after last hearing from Lois, I was on an NPR radio talk show, discussing “Treating the ‘Untreatable’.” The staff gave me an email from a former patient, saying that our work had saved her life. It was Lois, reaching out after all these years. We talked. She had done very well in life, had re-established contact with her children and had become a hands-on grandmother. She had remarried and had a full life with her third husband of more than twenty years and had survived his death with no retreat to psychosis. She had had a very successful career in her chosen field. Most importantly, there had been no further hallucinations or delusions and no more “antipsychotic” medication. She had learned well that understanding her internal phenomena and fantasies could take the place of a delusional psychotic reality. Her life was returned to her via an intensive psychodynamic psychotherapy.
From my perspective, having been free of delusions and hallucinations and off antipsychotic medication for more than thirty years, she is a prime illustration of Intensive Psychotherapy having CURED schizophrenia. So what have we learned here? We can see how a dynamic psychotherapy of psychosis has yielded not just understanding, but healing — giving up, long-lasting belief systems — and Cure of previously intractable psychotic appearing phenomena. We have seen that an inquiring exploration of the meaning to the patient of his or her hallucinations, delusions and strange thoughts leads to an understanding of the origin of these psychotic distortions of reality. With such an approach, Lois and many others have returned to a life of relationships and function.
How was such a treatment done? It was done via the usual empathic psychodynamic exploration of past events, of transference and countertransference phenomena and of affective states that occurred around the time of the development of symptoms. It is the usual psychodynamic psychotherapy, with the understanding that terrible, traumatic events may indeed have happened, and that intense phenomena may occur during psychotherapy.
Five things are most important.
First is the understanding that there is psychological meaning to the patient of his or her delusions or hallucinations; we have but to explore them in a fashion that allows the patient to integrate the information and to develop an observing self.
Second, and equally important, is the necessity for arriving at what Harry Guntrip called “the lost heart of the self.”(8) Sitting there with a person in this vulnerable state allows inchoate feelings to rise to the surface. Trust gradually develops, and soon the underpinnings of a delusional, hallucinatory, or other psychotic orientation become clear.
Third, it is crucial that the therapist understand that it is possible to peel the onion and get to the origin of the most bizarre and extreme psychotic phenomena. It certainly helps if one has had the experience of previously helping patients heal from schizophrenic and paranoid delusions, via the use of a psychodynamic psychotherapy.
Fourth, we as therapists of patients suffering from psychotic states must take a thorough history of both the patient and his or her psychotic productions. In the exploration, in the taking of a psychological history of how these strange occurrences started, we begin to establish a beachhead from which the patient can begin to observe and understand his or her own distortions and bizarre preoccupations.
Lastly, we must not shy away from those most disturbed and offer little but medication, halfway houses, partial care and daytime activities. We must engage the patient where their attention lies, in the world of psychotic thought. Most importantly, we must learn to speak schizophrenese; to understand and work with the patient’s own metaphor and symbolism, wherever it takes us. Not only does understanding develop, but isolation and alienation succumb to our therapeutic efforts to reach the person using his own language and meaning. Instead of being an isolated hallucinating terrified schizophrenic, he or she feels understood and cared for, no longer alone. As we engage psychotherapeutically and move toward the core of the person and the isolated, withdrawn self, defensive schizophrenic barriers melt and a person emerges. A person emerges quite capable of tremendous insight and change.
Often, clinicians attempt to treat patients such as Lois with the long-term use of “antipsychotic” medication, thereby blunting affect and never allowing the patient to fully explore the emotional and psychological underpinnings of psychotic distortions. The field of psychiatry has turned toward viewing psychotic patients as suffering from brain disease, hence prescribes medication in a far too facile and cookbook fashion. All too often. it is possible to use medications sparingly, often stopping them as the gains of an intensive psychodynamic psychotherapy lead to the exploration and understanding of previously bizarre seeming phenomena. For Lois, a psychodynamic understanding led to healing and the resolution of the previously debilitating delusional state. I would go so far as to say that for Lois, an Intensive dynamic psychotherapy has led to a lasting CURE, without continued medication and treatment after the previous seven years of heavily medicated treatment of schizophrenia left her in a seemingly ‘untreatable’ psychotic condition.
How have things changed in my practice with psychotic patients over the last 45 years? Not very much. If anything, I’m even more convinced of the benefits of psychodynamic exploration in the treatment of psychotic patients. Even back in the early 70s. I found myself looking at various regressive self states and inquiring into how they developed. From a similar four+ decades-long practice perspective, I question people’s delusional beliefs over time and tell them that I understand that they believe these things, but that to me it makes more sense to try to ferret out how such notions began.
As practitioners, we have the option of treating very disturbed psychotic patients with the usual amalgam of supportive psychotherapy and ancillary services, such as day care and repeated hospitalization, coupled with the excessive use of medication. Such an approach often leaves patients in the throes of the psychotic distortions with which they came in, continuing to fear their hallucinations and delusions and continuing to fear those out there who appear to orchestrate giant conspiracies against them. Such an approach often leaves patients consigned to excessive medication, with their lipid and glucose side effects, for life.
I prefer the option of a psychodynamic psychotherapy, with the judicious use of medication, in an attempt to help patients understand the origin of their psychotic symptoms and the meaning to them of their hallucinations and delusions. Such an approach often leads to the cessation of “antipsychotic” medication, healing and CURE of previously unfathomable psychotic dilemmae. Such was the case with Lois.
To my mind, the proper approach to a psychotic patient is to attempt to understand the meaning to him or her of psychotic phenomena. This can be coupled with either a short course of medication or the titration downward of medication, as the patient gains control of previously frightening and poorly understood psychological processes. What was once seen as coming from the outside, as something in the form of voices or delusions, as something over which one had no control, becomes fathomable and understandable, during the course of a psychodynamic psychotherapy of psychosis. When successful, such an Intensive psychotherapeutic approach leads to increasing acceptance and integration of oneself and one’s delusions and hallucinations. Most importantly, psychotic occurrences come under one’s own mastery as one realizes that hallucinations and delusions emanate from previously unconscious material within the self.
Such a psychodynamic approach runs counter to the general run-of-the-mill excessive prescription of medications, but gives the patient a chance to make sense of his psychosis and achieve lasting healing and sometimes CURE. Such was the fortunate outcome with Lois. And such is the possible outcome of an Intensive Psychotherapy of schizophrenia with many other patients.
Which would we as therapists prefer? A heavily medicated, debilitated patient, subject to delusions and hallucinations, overwhelmed by inner demons? Or a patient like Lois, who was that way when she came in, where we speak her language of symbols and metaphor, gradually leading to a CURE off all “antipsychotic” medication? The first leads to stasis, hopelessness and deterioration. An Intensive Psychotherapy may lead, as it did for Lois and many others, to a creative solution and toward a productive life of work and relationships, without debilitating hallucinations and delusions. Using Lois as a teaching example, we can see how an Intensive Psychotherapy of Schizophrenia may lead to a lasting CURE.
* * * * *
I want to thank Karnac Books for allowing the reproduction of material contained in “Treating the ‘Untreatable’: Healing in the Realms of Madness.”
Steinman, I, Treating the ‘Untreatable’: Healing in the Realms of Madness, Karnac Books, London, 2009
Garfield, D., Steinman, I., Self Psychology and Psychosis: The Development of the Self during Intensive Psychotherapy of Schizophrenia and the other Psychoses, Karnac Books, London, 2015
Kohut, H., How Does Analysis Cure?, University of Chicago Press, Chicago, 1984
Bockoven,J., Solomon, L ,(1975) Comparison of two five year follow up studies, American Journal Psychiatry, 132: 796-801
Mosher, L. (1987) Review of Recovery from Schizophrenia: Psychiatry and Political Economy by Richard Warner. Am. J. Psychiatry, 144: 956-957
Harrow, M., Jobe, T. (2007) Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. Journal of Nervous and Mental Disease, 195: 406-414
Trauma and Psychosis, International Society for the Psychotherapy of Schizophrenia. US National Meeting, Santa Monica, 2006
Guntrip, H, Schizoid Phenomena, Object-relations and the Self, International Universities press, New York, 1969
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Yes anti-psychotic meds often lead to hopelessness and statis, however, intensive psychodynamic therapy can be quite destabilizing and damaging too. To me, they are more similar in effect than not, and both require belief in falsehoods about yourself, overemphasize undeserved trust in a medical provider as source of healing and that trust can be easily broken, and are likely very expensive.
Psychodynamic psychotherapy is not delivered by a medical provider.
It’s so great to see this being published online for everyone to read! And good to see you using more modern technology to spread your knowledge 🙂
This paragraph below illustrates for me what’s so important about your approach and the psychodynamic approach in general:
“Such a psychodynamic approach runs counter to the general run-of-the-mill excessive prescription of medications, but gives the patient a chance to make sense of his psychosis and achieve lasting healing and sometimes CURE. Such was the fortunate outcome with Lois. And such is the possible outcome of an Intensive Psychotherapy of schizophrenia with many other patients.”
Your type of approach provides some hope and a sense of meaning via understanding scary, inscrutable “psychotic symptoms” as potentially meaningful and transformable. As you note in your book Treating the Untreatable – https://www.amazon.com/Treating-Untreatable-Healing-Realms-Madness/dp/1855756099 – many severely disturbed people have been in terror for years or decades due to lack of hope and not having a way of making sense of their experience.
Hope is like oxygen for people in extreme states and their families – too many such people are literally dying or nonfunctional because they are delusional / hallucinating / withdrawn etc, but they don’t have the hope that comes from an empathic, committed partner who believes their experience has meaning and that they can recover.
I expect that you may soon be hearing in these comments from others who think that therapy is universally harmful and unnecessary. I will preempt such comments by noting that psycho-therapeutic relationships are as varied and individual as human relationships, which is what they essentially are. Generalized statements about psychotherapy and what it does or does not do outside of a particular context are meaningless. However, large-scale studies of long-term psychotherapy by Falk Leichsenring, Paul Knekt, Barry Duncan, appear to show that – on average, and in about 80% of cases but not in all cases – people are emotionally and functionally better off when they engage in long-term psychotherapy than when they do not.
Leichesenring’s group is notorious for poor analysis and overstating outcomes.
I am not blanket denigrating psychotherapy. I definitely do believe that potential negative effects of psychotherapy are rarely looked by the same people who have sophisticated critiques of negative effects of psychotropic drugs. I don’t think psychotherapy should get a pass.
There are certainly many who have been harmed or more harmed by their experience in psychodynamic therapy as they had been with drugs, with even less recourse of action.
Psychotherapy is not like a pill that comes off an assembly line – the individual and constantly changing human relationships that are psychotherapy are much less able to be generalized about.
With intensive psychotherapy of psychosis, yes, it certainly can be harmful, as can any human relationships with a more (or less) troubled person. Intense rage and terror are usually underlying psychotic mental states, and if these are not processed safely then their emergence can be harmful or even deadly. Also, some therapists presume they know exactly what is wrong with the client and impose their view of how to fix things on the person, rather than listening to and collaborating with them. This can also be harmful.
However, there are many, many good therapists out there who understand how psychotic states form developmentally, are very patient and emphathic, and who do good, honest work with many people.
As for evidence, here is a large meta-analysis of psychotherapy with 2,600 people labeled schizophrenic – http://psychrights.org/Research/Digest/Effective/BGSchizophreniaMeta-Analysis.htm – which states:
“Our findings indicate that individual psychotherapy is associated with improved functioning in the majority of patients diagnosed with schizophrenia who receive it. We found that all forms of individual psychotherapy (psychodynamic, cognitive-behavioral, and non-psychodynamic supportive) were associated with an improvement in functioning for people diagnosed with schizophrenia, but that the largest improvement rates were associated with psychodynamic and cognitive-behavioral therapies… Individual psychotherapy is associated with improvement in functioning in people diagnosed with schizophrenia in the overall meta-analysis and in each moderator analysis of the data.”
We can always argue about which data is valid or not; but perhaps if you think therapy is harmful, you can produce data proving that it harms most people, i.e. is more harmful on aggregate than not. And just saying that some person’s analysis is poor and that they are overstating outcomes – without links to references and a well-reasoned explanation supporting this notion – is not convincing.
I never said I think therapy is harmful, I said that it can be harmful, and that we don’t have a good understanding of the extent of the harm, engage in informed consent processes about the risks of harm, and deny/obfuscate that harm with talk of “bad apples, individual relationships, readiness for therapy, some gains were made, etc.” This is troublesome to me.
I am skeptical of folks who make an enthusiastic case for psychotherapy without this understanding, when they advise caution to psychotropics because the developing understanding of potential harm and limits of zeal to its general use.
I am not in a place comb through research right now, I’ll post some later if you like.
Psychosis is symptom of infamous Schizophrenia,according to infamous psychiatry
bible DSM.Or symptom of bipolar disorder.The only psychotheraphy which is effective
and isn’t favored by many psychotherapists,is chemical induced hypnosis.The only
magical stick in psychotheraphy.Psychotherapists rarely use it,because if it does work,
it will reduce number of sessions with client and less sessions,means less money for
any psychotherapist.Because all of us Schizophrenics out there,already have problems,
with natural hallucinogens in our brains,any added hallucinogenic substance,won’t
be matter of real solution.
On biological level Schizophrenia and it’s symptoms,can only be triggered,by certain
hallucinogenic substances in human brains.Dopamine imbalance hypothesis,is still
the very only proposed explain,for phenomenon named Schizophrenia.Dopamine
isn’t in group of hallucinogenic substances.And this know every academic,who is
fluent with chemistry,or biochemistry.From various fields of modern and sadly so
corrupted science,that even Schizophrenics like me,can see beyond my psychosis
symptoms,very clear biological reality.
We shall see,if anyone can debunk my comment.
You have a point there, Borut. Oxidized adrenaline metabolites adrenochrome and adrenolutin are very long lasting hallucinogenic substances and adrenochrome is found in the human body. Read the later works of Abram Hoffer for details.
I have no wish to debunk your comment. I was glad to read it. Every time I encountered a statement about “dopaminergic pathways” and psychotic symptoms, I had a small sense that that was wrong, but discarded the thought. You seem to be saying unbalanced or excess dopamine can’t produce hallucinations because dopamine isn’t a hallucinogen. That’s more of a revelation than it should be!
Is experiencing hallucinations anything like being asleep and dreaming? If so, it would not require big fancy explanations for why some people hallucinate and others do not. The only thing to explain would be why some do it only while asleep.
Regarding delusions and hallucination of a schizophrenic.
From my perspective I was in a prison, those in power called a hospital. I was forced to take poison those in power called medicine. I had thoughts that those in power called hallucinations.
Who is the delusional one? The one who has no power.
“inner demons” is twice written in the text.
There are outer demons, and you must have money to pay the demons. Pay for your food, pay for your shelter, pay for your clothing et cetera.
How are you going to get your money?
In an age when medication is considered by many to be the only treatment for severe mental illness, it is good to see Dr. Steinman write about his success using psychotherapy to help very disturbed individuals. It brought to mind. A book I read many years ago, I Never Promised You A Rose Garden by Joanne Greenberg (published in 1964 under the pen name Hannah Green). This was an autobiographical novel in which the author described how she was cured of schizophrenia through psychotherapy with Frieda Fromm-Reichmann, a famous psychiatrist at the time. The author went on to be married and have children along with a sucesssful career. Since the book was published it has come under criticism from psychiatrists who claim Greenberg never really had schizophrenia, because, I suppose, they just can’t believe psychotherapy can cure a supposed brain disease.
Thanks for this well written summary of what is possible with therapy for psychosis, along with a clear example! This will be helpful to many…..
There is no such thing as schizophrenia, not as a mental illness.
The symptoms which we call clinical schizophrenia are simply the result of psychiatry, psychiatric medications, and psychotherapy, being used to denigrate and humiliate. What they do is try to make people believe that their distress is caused by something wrong with themselves, rather than about their degraded social position.
“The practice of psychotherapy is wrong, because it is profiting from another person’s misery.”
Political consciousness raising and political and legal action are what people need to become involved in. Win some victories, and their distress will evaporate.
When it comes to psychotherapy:
Please Join, Move From Talk To Action
Thank you – This article infuses me with hope!
Miracle cure bestowed by miracle bestowing hero…
where have we heard that story before?
There is no cure, let alone CURE.
Unless you mean therapists CURE themselves of their own NTBAH “need to be a hero” disorder.
Given chance and enough support, people do HEAL.
Helping them HEAL, offering ways to support them in finding their way to HEAL is a good thing
Pretending you can cure us mere delusion – and that’s YOUR disorder not ours.
There’s much good in this approach but it – or at least its telling, lacks the vital ingredient.
It’s never about the therapy or therapist – its always about the person whose life is upside down and the hard worth they do to find their way out and to live in a world that’s told them and still tells them they don’t have a right to.
Anyone and everyone else can help and play a role but only ever in supporting roles.
Drop the bollocks and find humillty and you’ll be able to help more people find their way to healing…
Do you accept my or bcharris comment here?Because it’s very interesting,that real biology
of madness,isn’t real mission for MIA staff,or writters.And why MIA support rebellion against
biology and evolution in matter of so called Mental Illness or disorders?
Borut, no I don’t agree with this idea that there is one real biology of madness and that that real biology may be only or primarily triggered by “natural hallucinogens” in people’s brains. I think psychotic states are caused by many different interpenetrating factors and that many of these factors are social and environmental experiences which affect biology. I wrote about these psychosocial factors, including citing John Read’s research, in my article on “Rejecting the Medications for Schizophrenia Narrative” that I believe you read.
We should also be clear again that “schizophrenia” is a label people are given, not one unitary illness people have or do not have, and psychotic states exist on a continuum of degree and constantly change in response to internal and external influences.
If you want to have psychological explains more important as biological one,
well this difference between me and most of you here.Only few of us on MIA
blogs then,are aware of real biology of madness.Most of you here are against
biology,because so called biological psychiatry and pharmacy.Biological psychiatry
have nothing to do with real biology,those who will claim different,are fools.Sadly
psychological explains aren’t solution,for most of us who are crazy.It’s worthless
for me or anyone who belief in biology,to wrote comments on MIA blogs.Sadly
most of people on MIA blogs live in false reality and only few of us here are in
Dear Dr Ira,
Thank you for promoting Genuine Recovery.
I was “diagnosed” originally in the Maudsley (Kings College) London. I had asked for Psychotherapy but was put on a depot injection instead. By 1984 after many hospitalizations and years on disability and a number of suicide attempts – I was “diagnosed” a lot worse.
I made my Recovery in 1984 through careful drug taper with the help of Psychotherapy.
Practical Psychotherapy worked for me:- When I quit the strong drugs I started getting Severe Anxiety attacks – and I had to learn how to let go of my thinking to level off (but once I balanced off I knew what to do).
The High Anxiety was dreadful – but over the years it’s gotten a lot better. I believe the “High Anxiety” was to to with the medication distorting my “dopamine system” as I didn’t have this type of thing before.
The Maudsley Hospital (Kings College) have spent Billions of Pounds on Biochemical Research into Severe Mental Illness in the last 30 years – But my 30 year Successful Recovery was as a result of abandoning this type of approach.
(In the past 30 years the new drugs produced have Shortened Life Expectancy and Increased Disability)
I appreciate what you are exploring here, Dr. Steinman, but isn’t “Using Lois as a teaching example…” rather dehumanizing? This is a big problem in the mental health field, I think. People can speak for themselves and tell their own stories. Lois’ story is filtered through you, and you are using her.
To be clear, I cannot bring myself to support books and articles written by mental health clinicians using their clients as examples of their professional success, or to prove a particular point about a healing modality. In graduate school, where I studied counseling psychology, most of my professors would do this, tell us students how their way worked with client after client, relating to us the stories of their clients, while at the same time bashing their colleagues’ (and my other professors’) methods and modalities. This was common, this dualistic competition–almost like back-stabbing, a bit gossipy, in fact–and then the inevitable examples of glowing, miraculous success with their clients via their own (brilliant, by implication) way of doing things.
We should be using only ourselves as examples, given that we are all human with human issues, and we all, equally, have healing, growth, and evolution to experience. It is our subjective experience that matters and has value to us, not what someone else says about us via observation. That’s not necessarily real, and in fact, usually is not based on the talked-about person’s reality in the slightest. I defected from the field of psychology, both professionally and in my quest for healing and wholeness, specifically because I see these norms and dynamics as toxic, purely. I feel they have created a very negative and energy sucking culture, quite frankly. How can meaningful core healing happen in that kind of environment?
With all due respect, I do honestly think this is exactly why this field has failed us all, and has created such mass delusion in all sorts of ways. This is not authentic to the client, with or without their permission to tell their story. So to me, there would inherently be distortion here. The client’s personal story is told through the filter of someone with a professional agenda, and I don’t believe that this would be the client’s actual reality, nor at all in their best interest. And to be true to my word and walk my talk, no, that is not for me to say, that would be for the client to say; but in my experience, this has tended to be the case, that we do not prosper by having someone else tell our story, explain us, or interpret us.
People need to speak for themselves to feel the power of their growth and healing. Otherwise, I’m reading only about the clinician telling the story, and not the actual protagonist–the honorable client. I know I’m being blunt, but I suffered through this for a long time, and finally got over it. But it really sucked more than anything I’ve experienced in life, practically destroyed me, and it is all because of this vampirism. Please stop “using” people. Thank you.
Thank you for this very interesting article. I have been told many times that, “if it looks like a Duck, walks like a Duck and quacks like a Duck, there is a very good chance it is a Duck”. Why do Clinicians, after observing ‘abnormal behavior’ in a patient with no apparent empirical evidence of a disease disorder, continue to think that chemical intervention is indicated?
I believe schizophrenia(SZ) is a behavior problem, pure, but not so simple. The thought process of those with SZ, has the effect of increasing the dopamine(DA) level, in a ‘all ready’ DA saturated brain. Left untreated with psychotherapy, this process will continue, unabated, until neurotoxins (glutamate etc.) begin to attack the DA receptor cells(the final stage).
All behavior is initiated in the subconscious mind microseconds before the conscious mind is aware. Behavior can best be modified at the subconscious level with psychotherapy(Hypnosis).
Keep up the good work Dr. Steinman, I believe you are on the right track.
There was nothing judicious about his prescription of drugs when I was forced to be his patient; his talk therapy involved no real conversation about anything and he made no attempt to discuss self image, problems, feelings, or anything. The man was like a parrot at best and a Pez dispenser far more often than that.
The ways he construed many of the things I said in sessions was beyond absurd and there I have never heard anything like it – I’ve seen confirmation bias in action before but never on this level. I don’t know what I did to anger this creep, but beyond this veneer of academia lies an angry old man who seemed to see a neatly categorized, predestined Patient and possible case study in me rather than being able to see a human being who was trying to come to terms with the gaping hole where his heart used to be.
This changes nothing of what was going on in my situation, but it should suffice as a warning to other individuals who end up in his office – just find someone else. There are plenty of doctors out there, and most are far more humble than this near Hollywood stereotype of the psychiatrist who thought he was able to “cure the incurable”.