The treatment of schizophrenia has long been a challenge for psychoanalysis. At the very beginning, Freud worked with patients who described a variety of severe and bizarre symptoms, and some of these responded to the new psychoanalytic method. Over the next half century, despite Freud's misgivings, many psychoanalysts worked with psychotic patients, some reporting good results. However, problems in accurate diagnosis and assessment made the validity of these outcomes uncertain. Some psychoanalysts, e.g., Paul Ferdern, tried modifications of classical psychoanalysis, while others, like Bryce Boyer and Peter Giovacchini, used traditional methods, including the couch. There were individual reports of therapeutic success. But neither classic psychoanalytic techniques nor depth interpretations used by the Kleinians seemed to produce reliable benefits. In the 1970s and 1980s psychoanalytic approaches fell into disfavor and the focus of treatment became pharmacological, not psychological. The absence of reliable research data on the beneficial effects of psychotherapy reinforced the developing focus on biological etiologies and treatments. However, after a half century of research, a definitive biological cause and therapy remain elusive, and there is renewed interest in psychological factors which play a role in schizophrenia. Today, psychoanalytic thinkers are focusing on what makes the psychology of schizophrenic patients unique and are trying to modify their technical approaches to address the particular way the mind works in psychosis. Future articles in this series will describe some of these new approaches.
Schizophrenia devastates individual lives and causes tremendous pain to family and friends. Its economic cost is enormous, estimated at $318 billion in the United States alone in 2002.
The modern treatment of schizophrenia has focused on medication management. Medication, though, has been only partially successful. In 1997, José Ayuso-Gutiérrez reported that 20-30 percent of patients do not respond. In 1996, Susan Essock and colleagues found that 48 percent of patients relapsed in the first year. Peter Weiden found that even if medication does work, studies find that 50 percent of patients stop taking their pills after one year, and 75 percent after two years.
The current treatment of schizophrenia is guided by a de facto research-clinical consensus: Schizophrenia is a progressive, biologically based disease. Treatment should focus on psychopharmacology that is ameliorative and not curative. Psychodynamic psychological therapies are ineffective and possibly harmful and should not be used.
Part of the trend in favor of medication resulted from the success of phenothiazines in reducing the number of hospitalized patients in the 1950s. But because of the limits of medication, we need to reconsider the role of other therapies, including psychodynamic psychotherapy. By definition, if a patient stops his medication, as so many do, no pill will induce him to take it. Some sort of psychological approach is necessary.
In order to reconsider the value of psychodynamic psychotherapy with schizophrenic patients, we should take a look at the case that has been made against it.
The belief that psychotherapy does not work with schizophrenic patients has been repeated throughout the psychiatric literature over the course of the last 30 years by such authors as Allen Bergin, Michael Lambert, Robert Drake, Lloyd Sederer, Thomas McGlashan, Kim Mueser, Howard Berenbaum, Jack Scott, Lisa Dixon, Anthony Roth, and Peter Fonagy. These views were formalized in two very influential reports: the Patient Outcomes Research Team (PORT) Study funded by the N.I.M.H. in 1998, and the Guidelines for the Treatment of Patients with Schizophrenia developed by the American Psychiatric Association in 1997.
The Schizophrenia Patient Outcomes Research Team report, observed in Recommendation 22:
“There is no evidence in support of the superiority of psychoanalytic therapy to other forms of therapy and there is a consensus that psychotherapy that promotes regression and psychotic transference can be harmful to persons with schizophrenia. This risk, combined with the high cost and lack of evidence of any benefit argues strongly against the use of psychoanalytic therapy, even in combination with effective pharmacotherapy.”
Andrew Lotterman, M.D., is a training and supervising psychoanalyst and associate clinical professor of psychiatry at Columbia University. He authored Specific Techniques for the Psychotherapy of Schizophrenic Patients. He maintains a private practice in New York City.
PORT cites a 1995 paper by Scott and Dixon:
“…there seems to be no evidence for the efficacy of dynamic insight oriented psychotherapies (either individual or group) for patients with schizophrenia. Indeed there is some indication that such therapies may be potentially toxic for these patients.”
The Guidelines of the American Psychiatric Association (APA) published in 1997 conclude:
“Intensive exploratory techniques during the acute phase of psychosis can prolong disorganization and precipitate relapse.”
The conclusions summarized above are drawn from less than a handful of papers that became influential. However, there are prominent flaws in these reports; they are (1) poorly designed, (2) based on opinion (or even hearsay), (3) not derived from direct clinical observation, and (4) sometimes involve anecdotal data from one or two patients. Here are the most often cited:
In 1986, Drake and Sederer published a single case as told to them by a patient and his family describing a five-time per week psychotherapy, conducted years earlier. The authors relied on the patient's and family's account exclusively. It is not clear what the training and expertise of the therapist was, what the psychotherapy methods were, what the duration of this therapy was, or how the outcome was measured. The patient developed a delusion, and later dropped out of individual treatment. In a later hospitalization, he became threatening during group psychotherapy. On the basis of this single case report and an equivocal research study from the 1960s conducted by George Fairweather and colleagues, Drake and Sederer conclude that intensive psychotherapy is harmful to schizophrenic patients. They use the analogy of pouring hot oil on a wound, a discredited medical procedure. The force of their argument lies more in the evocativeness of their metaphor than the clinical data.
Drake and Sederer's paper was cited by Mueser and Berenbaum's 1990 editorial, which was to have a major impact on both the PORT study and the APA guidelines. Mueser and Berenbaum reviewed the literature on psychotherapy with schizophrenic patients and concluded that there was little evidence that it was effective. They reviewed four controlled clinical outcome studies published from 1968 through 1984. Two of the studies found no beneficial effect for psychodynamic psychotherapy; two of the studies found that psychodynamic treatment was better than antipsychotic drug therapy. However, the authors acknowledged that all the studies had serious methodological flaws. Mueser and Berenbaum recommended a “moratorium on the use of psychodynamic treatment for schizophrenia based on lack of evidence of usefulness and use of resources.”
“While medication had kept me alive, it had been psychoanalysis that helped me find a life worth living.”
Like Drake and Sederer and Mueser and Berenbaum, Scott and Dixon did not themselves conduct research with schizophrenic patients but, rather, reviewed the literature. They acknowledged that most studies were flawed and the results could not be generalized. Despite this, they offered an opinion: “[There is] no evidence for the efficacy of dynamic, insight oriented psychotherapies (either individual or group) for patients with schizophrenia. Indeed there is some indication that such therapies may be potentially toxic for these patients.” What is this evidence of toxicity? They cite the article by Mueser and Berenbaum, which in turn cites Drake and Sederer. Scott and Dixon thus, via a chain of repetition, use the evidence in Drake and Sederer's paper, which consisted of one anecdotal case and Fairweather's 1960 problematic report. Repetition seems to have lent authority to these claims, which were questionable when they were first put forward, and makes them appear to be definitive. It is essentially these claims that were formalized in the PORT study and APA guidelines. In effect, all roads lead back to Mueser and Berenbaum, and from there, to Drake and Sederer.
To add a comment about the PORT study: It relied on a panel of psychiatric experts. Each was asked to vote on whether these certain clinical practices were recommended or not, based on his or her “knowledge of the literature.” PORT was thus essentially an opinion poll. The experts made recommendations based on what they read, not on direct research experience. It is not clear whether the experts had any direct clinical or research experience with schizophrenic patients. There was no new information in Recommendation 22 which went beyond what existed in the literature that I have reviewed above.
To summarize: Research evidence that psychodynamic psychotherapy is beneficial is inconclusive. However, for the present, the same might be said of psychotherapy or psychoanalysis with neurotic patients. Outcome research for psychotherapy of any kind and with any category of patient has historically been notoriously difficult. I want to emphasize this however: There is no actual research or clinical data to show that psychodynamic psychotherapy is harmful to schizophrenic patients.
I have reviewed the data that opponents of psychotherapy with schizophrenic patients have cited. But, there are statistics
which support psychotherapy. A variety of studies have reported that psychological treatment with schizophrenic patients is effective. Cognitive behavior therapy has been shown to be useful, and studies have shown that psychodynamic therapy can also be helpful. In 1997, Gerard Hogarty reported the benefits of his version of individual psychotherapy, which he termed “personal therapy.” Moreover, in a 2002 meta analysis of 37 studies involving 2,642 patients, William Gottdeiner and Nick Haslam found that “Individual psychotherapy can be effective even without the concurrent use of antipsychotic medication.” There are also reports by patients themselves who emphasize the importance of talk therapy. In her 2007 autobiography Elyn Saks said “While medication had kept me alive, it had been psychoanalysis that helped me find a life worth living.”
In the debate among researchers, who is right? Right now, we simply do not have enough good data to know. While schizophrenia has a significant biological component, environmental and psychological factors also play a significant role: 60 percent of women patients diagnosed as schizophrenic had a history of childhood sexual abuse; 77 percent of sexually abused children admitted to psychiatric hospitals were psychotic as compared with 10 percent of children who were not abused. Every symptom seen in schizophrenia, whether positive or negative, has been associated with environmental trauma. Auditory hallucinations, visual hallucinations, paranoid ideation, thought disorder, loss of reality testing, and even Capgras syndrome have all been linked to post traumatic stress disorder. Mark Hamner found that schizophrenic patients scored only slightly higher on the positive symptom scale of the Positive And Negative Syndrome Scale (PANSS) than PTSD patients. Remarkably he found that the scores on the negative symptoms scale were identical. Otto Doerr-Zeggers and Patricia Herbst found a connection between torture and negative symptoms.
Psychotherapy is not a panacea for all schizophrenic patients. Although it is fraught with difficulties, in certain cases it can be very useful. It can be helpful in building a therapeutic alliance that leads to the acceptance of medication. In certain cases of acute onset psychosis, it has been associated with the resolution of symptoms even when medication has failed. In some cases of chronic psychosis, it can be associated with slow but sometimes dramatic improvements in psychological and social functioning. Unfortunately, for now we cannot identify which patients will benefit from this approach, and which will not.
Attempts at psychotherapy with schizophrenic patients in the past have suffered from a lack of specificity. Standard psychotherapy technique was originated for patients with neurotic psychological structure. Recently, new approaches have been developed which take into account the particular psychological and cognitive structure of schizophrenia (e.g., the lack of self-object boundaries, the breakdown of language use). Eric Marcus, David Garfield, Hogarty, and I have developed such approaches.
Based on the clinical experience of a variety of psychotherapists, and on patients' own reports, psychotherapy can help at least some schizophrenic patients. First, accurate interpretations can help bring disruptive unconscious affect and fantasies to the surface, and can reduce their disorganizing effects. Second, accurate interpretations can be seen as a sign of the therapist's personal interest and commitment, which leads the patient to feel accepted, and thus not so alone and inhuman. Because the interpersonal world of psychotic patients is so eccentric and isolated, the crucial experience of feeling understood and significant may not exist outside the therapy. Withholding psychotherapy is not a neutral step. It can deprive a patient of essential emotional contact. Menacing fantasies and emotions, will not simply disappear if the patient avoids psychotherapy. In the end, it is not psychotherapy that introduces terror into the schizophrenic patient's life.