Although psychotherapy is a core treatment in psychiatry, it is currently underutilized in the management of schizophrenia.
Schizophrenia afflicts roughly 1% of the global population and has long been considered the most severe and debilitating psychiatric disease. Since the discovery of the phenothiazines in the 1950s, a gradual shift away from psychotherapeutic and toward biological therapies has ensued.
Nevertheless, psychological and psychodynamic models of schizophrenia form an important part of a biopsychosocial approach, and significant evidence spanning several decades supports the use of psychotherapy for these patients.1
Unfortunately, many patients with schizophrenia receive no form of psychotherapy, and most young psychiatrists and psychotherapists graduate with no exposure to psychotherapeutic methods for this population. Some carry the misconception that psychotherapy is ineffective or unimportant in the treatment of psychotic patients, an idea that has its roots in a decades-old ideological war within psychiatry and not in scientific or clinical reality.
(For these reasons, I have recently developed a seminar on the psychotherapy of schizophrenia for the residents I teach at Tufts Medical Center and the University of Central Florida.)
The psychotherapy of schizophrenia has a long history that predates the discovery of the neuroleptics and electroconvulsive therapy by several decades. Freud believed that individuals with schizophrenia were inaccessible to psychoanalysis, but maintained that later modifications to psychoanalytic technique might render the patient treatable in psychotherapy. Adolf Meyer, MD, the first psychiatrist-in-chief at Johns Hopkins Hospital, developed a psychological theory of schizophrenia in the early 1900s.
In the mid-20th century, a number of psychoanalysts—including, most notably, Harry Stack Sullivan, MD; Silvano Arieti, MD; and Harold Searles, MD—studied schizophrenia from the psychodynamic perspective. Perhaps the most comprehensive text on the psychotherapy of schizophrenia, Interpretation of Schizophrenia, was published by Arieti in 1974 and won the U.S. National Book Award in the science category the following year.
Other and more recent contributions to the psychotherapy of psychosis have been made by psychoanalysts Bertram Karon, PhD; Michael Robbins, MD; and Michael Garrett, MD, among others.
The Psychodynamic Approach
At the heart of the psychodynamic approach to schizophrenia is the idea that psychotic symptoms are not random or meaningless phenomena, but rather rich, symbolic expressions of the patient’s inner world. Hallucinations and delusions are concrete representationsof abstract ideas, wishes, and conflicts.
These symptoms develop in response to an overwhelming and intolerable self-image. As Arieti noted, “[When the patient] can no longer 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.”2
In his recent text titled Psychotherapy for Psychosis, Garrett summarizes the psychodynamic approach to schizophrenia1:
“Psychotic persons use figurative language in idiosyncratic ways. Driven by intense, unbearable affects, they construct concrete metaphors and fanciful delusional identities that are meaningful expressions of their emotional lives. These constructions are regarded by others as alien and incomprehensible because the associational links in the psychotic person’s figurative language are not readily accessible to the average person. A central aim of psychodynamic work in psychotherapy is to help patients reconstruct the emotional meaning of their psychotic symptoms in the protective holding environment of the therapeutic relationship.”
In psychodynamic terms, patients with schizophrenia engage in concretization and perceptualization. The latter term refers to the process of transforming abstract concepts into specific sensory perceptions. For instance, patients who think poorly of themselves may smell a foul odor emanating from their body; the rotten self-perception becomes the rotten body that smells.2
In the absence of sensory perceptions (eg, in patients who experience delusions without hallucinations), concretization is used. This refers to patients who project onto the outside world their self-condemnation and come to believe that others are targeting them. Perceptualization can be considered the most advanced level of concretization.
Negative symptoms can be interpreted similarly. The typical schizophrenic defense is withdrawal, and negative symptoms may be a strategy intended to shield patients from the painful consequences of social contact. They may also serve to protect patients from fears related to positive symptoms, such as patients who isolate themselves in their room to avoid those they believe are persecuting them.
We must remember that the patient’s need for communion with others is great, and that a part of the patient—the part that remains healthy despite the psychosis—yearns for human relationship.
An unfortunate misconception is that psychodynamic therapists maintain that the origin of schizophrenia lies in disturbed relations with the patient’s mother. This idea has been discarded by most psychoanalytic theorists since the 1970s.1,2 Still, it is true that family dysfunction, attachment problems, and other adverse events in childhood contribute to the development of schizophrenia in some patients.1,3-4 A biopsychosocial approach considers these environmental forces in the etiology of the disease.
Since there is no single psychodynamic approach to the psychotherapy of schizophrenia, I will briefly describe my own approach, which has been informed by the work of Arieti.5 Patients with schizophrenia generally come to treatment fearful and anxious, just as they are fearful and anxious of any interpersonal contact.
The early stages of therapy must be focused on relaying to patients a sense that they are no longer alone in the world—that at least one relationship, the relationship with the therapist, need not produce overwhelming fear. At this stage, every effort must be made by the therapists to form a connection with the patient.
As therapy proceeds, and once basic trust with the therapist has been established, therapists may begin to offer interpretations regarding the nature and meaning of patients’ symptoms. These interpretations may not be particularly helpful at first, but in time, patients may be able to entertain the possibility of these interpretations.
The formation of symptoms is discussed as an attempt to resolve a painful and untenable situation. Patients are taught that psychotic symptoms are often preceded by a change in one’s emotional state, and that it is possible to catch themselves in this listening attitude2 before the occurrence of the symptom.
A patient of mine said this about our 5-year psychodynamic treatment:
“The work didn’t click for me until years in. Every psychotic experience was always preceded by a split-second shift in my emotional state. Over time, I was able to feel this window open up… and my experiences slowly dissipated. I still experience psychotic symptoms but at a much less frequent rate. Every session, a new layer of what has happened to me is unraveled through therapy. Almost every time a link has been discovered, I subsequently experience [fewer] symptoms.”
Although it is true that we cannot promise the patient a rose garden (to borrow a phrase from Frieda Fromm-Reichmann, MD6), with intensive psychodynamic psychotherapy, many patients reach levels of integration and self-fulfillment that far exceed those prevailing before the patient became psychotic.7
Psychotherapy is a core treatment in psychiatry8 and has a long and rich history in the treatment of schizophrenia. Nevertheless, it is currently underutilized in the management of this disease.
In the author’s experience—and consistent with some recent data—the psychodynamic method, which is best considered a complement to pharmacotherapy, can help patients make sense of their odd and seemingly senseless experiences and reconnect them to the outside world. It forms an important part of a biopsychosocial approach to the most fascinating and complex of human illnesses.
Dr Ruffalo is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando and an adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He is a psychoanalytic psychotherapist in private practice in Tampa, Florida.
1. Garrett MG. Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment. The Guilford Press; 2019.
2. Arieti S. Interpretation of Schizophrenia. 2nd Ed. Basic Books; 1974.
3. Gumley AI, Taylor HE, Schwannauer M, MacBeth A. A systematic review of attachment and psychosis: measurement, construct validity and outcomes. Acta Psychiatr Scand. 2014;129(4):257-274.
4. Hardy A, Fowler D, Freeman D, et al. Trauma and hallucinatory experience in psychosis. J Nerv Ment Dis. 2005;193(8):501-507.
5. Ruffalo ML. Understanding schizophrenia: toward a unified biological and psychodynamic approach. Psychoanal Soc Work. 2019;26(2):185-200.
6. Greenberg J. I Never Promised You a Rose Garden. Holt, Rinehart & Winston; 1964.
7. Rosenbaum B, Harder S, Knudsen P, et al. Supportive psychodynamic psychotherapy versus treatment as usual for first-episode psychosis: two-year outcome. Psychiatry. 2012;75(4):331-341.
8. Ruffalo ML, Morehead D. Psychiatry and psychotherapy: the great divorce that never happened. Psychiatr Times. 2021;39(7):24-25.