IRA STEINMAN M.D.

I was on a radio  show two years ago, talking about “TREATING the ‘UNTREATABLE, Healing in the Realms of Madness”. Before the  show began, the staff gave me an email. They had apparently read the content of the email, for they presented it to me in a hushed and nearly reverential way. It was a lovely email from a former patient, telling me how much I had helped her more than three decades earlier. I pondered and tried to get a fix on who it was.

Suddenly, it became clear to me. It was “Lois” , the protagonist of “Two Rats and the Extraterrestrial” in TREATING. I hadn’t heard from her for more than 25 years. After the show, I contacted her. We talked and traded emails on a number of occasions over the intervening time. Here’s her tale.
Lois was a depressed, withdrawn, woman in her mid thirties, when she consulted me.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 anti-psychotics. She had lived in a half way house for the better part of a year 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 schizophrenia had been made during one of her first hospitalizations, when she told a psychiatrist about the two rats gnawing at her. The diagnosis was more correct than he knew, but, by failing to help her try to fathom the meaning of two rats gnawing at her, he missed the opportunity to open a pathway to an understanding of her 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 may lie a key to the code of the person’s thinking. Some time, it may take years; here it was much simpler.
The opening lay in the rats gnawing at her. Did they mean anything to her? 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. 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. 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 possible content and meaning?
What did the two rats mean? She didn’t know. I had some sense immediately, for she had two children. When did the image begin. It was during the long (six month) hospitalization after the birth of her youngest child, when she couldn’t bear to see them, felt terribly guilty about being away from them, yet unable to handle any interaction with them. Could the number two relate to her two children I asked, burrowing into her as her own feelings of loss and guilt about not being involved with her  children burrowed into her? 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, the meaning would most likely become clear, as did the meaning of the two rats .But the issues involved are, for whatever idiosyncratic reason, 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 themself.
She agreed that the rats might represent her children gnawing at her feelings. She seemed comforted by this sense, and much more willing to bring up historical and, gradually, 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 delusion, a delusion from those early years of life 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 unforseen 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, the expected for someone who has broken the bounds of reality. She created a further delusion, this time 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  rats which we had deciphered , perhaps because she felt we both could speak the same language, the language of understanding the meaning of delusional imagery.
Since his death more than twenty years ago, 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 moldering 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 a 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 world of a 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 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 doing drugs 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 after the birth of their second child.
A delusional reality is both fragile and rigid. Patients cling to delusions tenaciously and, once having created delusions, have the propensity to become delusional in every which way. Lois had 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.
Once delusional, one is always vulnerable to delusional crises and regressions, until the delusions and the mechanisms of delusion formation are explored and understood. Once one has fractured the bounds of reality, for whatever reason, one is prone to increasing delusion formation. 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 to playful to destructive and terrorizing. In the process, one’s actual self gets buried under a layer of self obfuscating phenomena.
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 how 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 constantly with her evaporated over a period of about three months, with a few several day hospitalizations to keep her from harming herself. 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, if anything, meant more to her as a delusional object (figure) than as a real and loving person.
This relinquishing of the delusion of her father was aided by the development of a transitional, short term delusion of her two children constantly by her side. In short, she substituted her children for her father in delusion land. (Once open to delusions, there are no end to them.)
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 her yearning for those she loved.
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 all her energy on her children. Without internal delusions taking up her loving vital energy, she was able to reestablish a very good and continuing relationship with her children. In addition, she became quite successful at two differing 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 blockage and death. She finished therapy, having more than achieved gains she never had dared to hope for. Foe several years, she  kept in touch by mail,  maintaining the gains of an exploratory psychotherapy of delusions, without resort to dramatic and delusional representations of feeling states.

Twenty five years later, when I heard from her after the radio show, life was good for her. Sure, there had been difficulties, but she had negotiated them. She had reestablished contact with her children, had remarried, worked, lived happily with her new husband and even dealt with his death. She was involved in life and activities and the lives of her children and grandchildren. Most importantly, she had done this on the basis of the Intensive Psychotherapy we engaged in, as described in TREATING the ‘UNTREATABLE’. This previously often hospitalized woman, who was a “burnt out case”, loaded up on all kinds of antipsychotic medications by a number of psychiatrists, hospitals, half way houses and day care settings for seven years  prior to seeing me, hadn’t taken any antipsychotics for over thirty years. Her antipsychotic medications were gradually titrated down as  her delusions and hallucinations were understood and worked through. She had had none of the hallucinations and delusions she had before she came to see me, hallucinations and delusions that were readily comprehensible during the uncovering, exploratory work that we did.

It was a great pleasure for me to know that Lois had  weathered the storms of her psychosis and her previously inept and stultifying treatment with the usual evidenced based therapies available at that time. It was an even greater pleasure to realize that the gains of our two and a half years of Intensive Psychotherapy had lasted over the intervening decades and that Lois had built a life for herself. Most importantly, it remains a deep pleasure to know that our Intensive Psychodynamic Psychotherapy led Lois out of the morass of psychosis and the oft repeated diagnosis of Paranoid Schizophrenia into a world where she leads a full life as a functioning person. For Lois and her Intensive Psychotherapy, the word CURE seems appropriate.

But how can schizophrenia be cured? Isn’t it a brain disease? How can talking change the brain?

Intensive Psychotherapy can be transformative. It was for Lois and it has been for others. How does it transform? By talking about and working through the patient’s own metaphor, concretized into hallucinations and delusions. My fingers typing are the result of brain reactions and chemicals. When a person is beset by his own thought productions and doesn’t recognize that they come from within, it is a small step to become either terrified or enraged or dissociated; or some combination of each. All of these reactions have a chemical substrate.

As issues are worked through, as hallucinations and delusions are metabolized psychologically, a person begins to calm. Brain chemistry, as Susan Vaughan describes in The Talking Cure, changes in the neurotic person as issues get worked through. In the psychotic person, sometimes one gets lucky and understands the origin of psychotic thought, as was the case with Lois and others in TREATING the ‘UNTREATABLE”. When this happens, there is calming and the ability to give up hallucinations, delusions and other forms of psychotic thinking. Often, antipsychotic medications can be titrated down and sometimes stopped as comprehension replaces terror.And of course, brain chemistry changes when someone is not constantly in a state of excitement and on alert.

So Lois got cured and Paranoid Schizophrenia was cured and Brain Chemistry Changed as Lois understood her issues and realized that what seemed  to come from the outside, really came from within. And this has lasted over thirty years, with no antipsychotic medication.

Not bad for Intensive Talk Therapy of Psychosis