21 Sep 2013

The current state of the psychodynamic treatment of psychosis

Introductory remarks from a Seminar “Intrattabili” at I Seminari del Centro Psicoanalisi Romano, in Rome on October 5th, 2013

“There is nothing new under the sun”

When my good friend and colleague, Riccardo, asked me to write a chapter in his book on the subject of whether or not there is anything different in the way I currently treat psychotic people, I was a little perplexed. For my answer would simply be “Not really”. In fact over the last more than 40 years of treating severely disturbed patients my approach hasn’t changed much at all . Perhaps the field of the psychodynamic psychotherapy and psychoanalysis of schizophrenia and other psychoses has changed a great deal, but I have not changed much at all in my approach I tend to inquire into the nature of severe distortions of reality inquire as to how the patient developed hallucinations, delusions and bizarre phenomena of thought and action. 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 counter-transference 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, almost 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 those 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 initial 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 are treated with an amalgam of more and more medication, with less and less of an attempt at elucidating how these various states began. Unfortunately, contemporary psychiatry views nearly all psychosis as an expression of brain diseases.
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 needs 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, in fact. A closer look at the origins of psychotic thinking in people who end up becoming 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, meant to help someone look at psychodynamic issues that have played a major part in the development of psychosis, becomes a treatment for life. Of course, I use antipsychotic medication if necessary but generally for a short period of time. This use can be during a period of crisis , of intense anxiety or psychotic decompensation into delusional beliefs, alter personalities, hallucinations bizarre thoughts and feelings. There are many cases that exemplify the type of work that I do; suffice to say that a large percentage of my psychotic patients respond to psychodynamic exploration, often titrating down and stopping antipsychotic medication.
Several years ago colleagues and I held a meeting 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 the years of practice, I have had quite a number who easily fit into that way of looking at psychosis.
As length permits let me highlight several recent cases that demonstrate how painful external, hence internal, events led to dissociation or withdrawal into a world of psychotic thought. Even though these patients had come to me from a psychiatric hospital setting, psychotic thinking and symptoms ceased once the origin of psychosis had been understood by the patient and me and worked through in the usual psychodynamic psychotherapeutic fashion

Patient  Material.

So what have we learned here. Nothing new. Yet again, 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 again. 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, these two patients 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 counter-transference 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..

Three 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 it in a fashion that allows the patient to integrate the information and to develop an observing self.

Secondly, and equally important, is the necessity for arriving at what Harry Guntrip called “the lost heart of the self”. 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.

Thirdly, 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.

Often, clinicians attempt to treat patients such as either Amanda or Alfred with 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 the psychodynamic psychotherapy lead to the exploration and understanding of previously bizarre seeming phenomena.

This was done with Amanda in the usual way, making sense of different psychotic experiences, and paying attention to terrible traumatic events that led to fragmentation and eventual psychosis. With Alfred, it was necessary to be much more direct and confrontative, urging the cessation of marijuana use and questioning the far-flung nature of his paranoid delusional beliefs. Here too, a psychodynamic understanding led to healing and the resolution of the previously debilitating delusional state.

How have things changed in my practice with psychotic patients over the last 40 years? Not very much. If anything, I’m even more convinced, than I was then, of the benefits of psychodynamic exploration in the treatment of psychotic patients.

Even back in the early 70s. I found myself looking at various 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 them, but that to me it makes more sense to try to ferret out how such notions began. Such an approach worked very nicely with Alfred.

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 antipsychotic 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 antipsychotic medication, with their lipid and glucose side effects, for life.

I prefer the option of a psychodynamic psychotherapy, with the judicious use of antipsychotic 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 and healing and cure of previously unfathomable psychotic dilemmae.

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 antipsychotic medication or the titration downward of antipsychotic medication, as the patient gains control of previously frightening and poorly understood psychological processes. What was previously 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 psychotherapyof psychosis.

Most importantly, psychotic occurrence become under one’s own control, 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 antipsychotics, 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 Amanda, and Alfred.

Ira Steinman, M.D.

San Francisco