Since the birth of psychotherapy with Freud, most therapists have avoided treating patients with schizophrenia. Freud’s original conceptualization of the disease was as a narcissistic neurosis. He deemed the schizophrenic unable to develop a transference reaction and thus as unanalyzable. Nevertheless, he believed that future modifications to analytic technique could render schizophrenia accessible to psychotherapy.
In many ways, Freud’s original conceptualization of the disease accounts for the general avoidance amongst psychotherapists when it comes to treating schizophrenia. With few exceptions—such as Harry Stack Sullivan and Silvano Arieti (see my article on Arieti here)—psychiatrists have historically avoided undertaking the psychotherapy of schizophrenia, focusing instead on managing the symptoms with neuroleptic medications and other physical treatments.
However, recent research has demonstrated that a psychotherapy-focused treatment of schizophrenia (in combination with low doses of antipsychotic medication) is superior to the standard medication-driven treatment (Kane et al., 2016). As a psychotherapist who devotes the majority of my practice to treating patients with schizophrenia, I can attest to the benefit of psychotherapy for this difficult and debilitating condition.
In teaching psychiatry residents and social work students, the most frequent question I get when I tell them that I practice talk therapy for schizophrenia is some variant of, “How do you talk with someone who is so removed from reality?” It’s a fair question, but one that is based on certain misconceptions about the disease state itself.
Perhaps the most enduring, and harmful, myth about schizophrenia is that the symptoms of the disorder—most notably, the hallucinations and delusions—are meaningless and random and thus uninterpretable phenomena. To some, it makes no sense to consider why an individual might be hearing voices telling them they are worthless, smelling a poisonous gas in their home, or believing that a government agency has targeted them. If one sees these experiences as mere manifestations of biologic abnormality as opposed to a complex biopsychosocial problem, then psychotic symptoms will appear devoid of any meaning or significance.
It should be noted that this reductionistic view is not one endorsed by most theoretically-minded academic psychiatrists. See my article with psychiatrist Ronald Pies here which touches on the myth that psychiatrists see schizophrenia and other mental disorders as mere “chemical imbalances.”
Silvano Arieti and the Psychoanalytic Wisdom
The psychiatrist Arieti brilliantly described the process of schizophrenia as involving a series of events gradually setting the stage for the onset of the psychosis. In his award-winning 1974 book Interpretation of Schizophrenia, Arieti writes, “[When the patient] cannot change the unbearable situation of himself any longer, he has to change reality. . . . His defenses become increasingly inadequate. . . . The patient finally succumbs, and the break with reality occurs.” Central to Arieti’s view is that anxiety, and the patient’s inability to deal with it, plays a chief role in the development of psychotic symptoms.
Of paramount importance in the psychotherapy of schizophrenia is the establishment of basic trust through a warm and caring attitude and exchange of feelings between patient and therapist. When the patient comes into therapy, he typically feels unaccepted and unacceptable, distrustful of any interpersonal contact, especially with figures of authority, to the point of paranoia. Thus, the countertransference—how the therapist comes to relate to the patient—is the single most important tool in the analytic treatment of schizophrenia. In the words of Sullivan (1956), the therapy must offer patients a “relationship of security beyond what they have ever had.”
Psychoanalysts see psychotic experiences—such as hallucinations, delusions, and catatonia—as symbolic representations of internal conflicts, ideas, and wishes. The patient with schizophrenia engages in a psychological process known as concretization wherein the abstract is transmogrified into definite, concrete representations or forms. Auditory hallucinations, for instance, may appear as blame directed towards the patient who deals with his or her thoughts as if they were fact.
Interpretation has long been considered the mainstay of analytic psychotherapy; however, in treating schizophrenia, interpretations are not very important, at least not initially, but can be beneficial later on in the treatment. Arieti writes, “If the anxiety is decreased to the point that acceptance of the psychotic world is no longer immediate or automatic, it is possible to explain to the patient how he concretizes symbols. A patient of mine could recognize that the olfactory delusions about a bad odor emanating from his body were only concrete representations of what he thought about himself” (Arieti, 1959).
It is a sad reality that very few therapists have interest in psychotherapy for schizophrenia, and given the current state of the American mental health system, few patients have access to it. As Frances (2013) and others have pointed out, there has been a gradual trend in psychiatry towards treating the “worried well” and away from treating the seriously and persistently mentally ill. Those who do specialize in schizophrenia have focused more on genetic and biological factors—a worthy endeavor—but there has been a grossly inadequate emphasis on psychotherapy treatment.
Schizophrenia is a condition that afflicts 1% of the global population and results in widespread suffering and disability. As a result of changes in the mental health system, many with schizophrenia end up homeless or imprisoned. It’s time we reinvest in the care of the most vulnerable in our society. Psychotherapy, in combination with medication, can be an effective treatment for those with this serious disease.
Image: Self-portrait of a person with schizophrenia.
Arieti, S. (1959). American handbook of psychiatry. New York: Basic Books.
Arieti, S. (1974). The interpretation of schizophrenia (2nd ed.). New York: Basic Books.
Frances, A. J. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: HarperCollins.
Kane, J. M., Robinson, D. G., Schooler, N. R., Mueser, K. T., Penn, D. L., Rosenheck, R. A., . . . Heinssen, R. K. (2016). Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE Early Treatment Program. American Journal of Psychiatry, 173(4), 362-72.
Sullivan H. S. (1956). Clinical studies in psychiatry. New York: Norton.