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IJP 48:559-572 (1967)

The Separation of Management from the Therapeutic Setting in a Paranoid Patient1

Author: Alfred Flarsheim

ESTABLISHMENT OF THERAPEUTIC SETTING

I will describe certain technical procedures used in the treatment of a paranoid adolescent. This was an attempt to construct an environment within which potentially disruptive forces, stimulated by the patient's relationship with his mother, could be turned to therapeutic use.

The patient is a severely disturbed young man, and from the standpoint of life adjustment, the treatment was not a "success story", but it offers us an opportunity to discuss very important questions.

First I will delineate the therapeutic setting, and then the way in which this paranoid patient made use of it. The following phases could be separated:

i.Localization and control of his paranoid expectations as a result of the treatment alliance.
ii.Active staging of an assault by his mother on his therapy—the kind of assault which he had previously had to undergo alone.
iii.Regression to an organized dependent state, after his therapy survived. During the regression, he (a) developed painful somatic symptoms which led to our discovery that (b) he assumed that I was providing magical protection and assistance, and (c) he accepted and utilized physical care in a nurturing, sustaining relationship with his mother which was a new achievement for them both.
iv.Emergence from the regression, with the retention of some of the vividness of perception and feeling that he had first experienced in the painful somatic symptoms.

First Contact with the Case

My first contact with the case was a telephone call from the patient's mother. She requested that I see her 17-year-old son who had been diagnosed as a schizophrenic while currently hospitalized. I offered to see him in my office, although she had expected that I would see him in a hospital.

She described her son as very disturbed and at the same time as conforming and capable. As so often in the late adolescent, both were true, i.e. that he could at times adjust to the outer world despite severe inner disturbance. She s

IJP 48:559-572 (1967)

The Separation of Management from the Therapeutic Setting in a Paranoid Patient1

Author: Alfred Flarsheim

ESTABLISHMENT OF THERAPEUTIC SETTING

First I will delineate the therapeutic setting, and then the way in which this paranoid patient made use of it. The following phases could be separated:

i.Localization and control of his paranoid expectations as a result of the treatment alliance.
ii.Active staging of an assault by his mother on his therapy—the kind of assault which he had previously had to undergo alone.
iii.Regression to an organized dependent state, after his therapy survived. During the regression, he (a) developed painful somatic symptoms which led to our discovery that (b) he assumed that I was providing magical protection and assistance, and (c) he accepted and utilized physical care in a nurturing, sustaining relationship with his mother which was a new achievement for them both.
iv.Emergence from the regression, with the retention of some of the vividness of perception and feeling that he had first experienced in the painful somatic symptoms.