The Road Less Travelled: Psychodynamic Therapy of Schizophrenia

As I move closer to my retirement years, I feel compelled to write about my over 40 years of working from a modified psychodynamic/humanistic perspective with individuals challenged by serious mental health issues. Reviewing the literature over the last 100 years or more on this topic can be quite daunting. What appears to be most important is providing the most proven evidenced based treatments to those struggling with psychotic disorders. Even in the arena of psychotropic medications, not only are the medications effectiveness being addressed, but more importantly how the quality of life is affected. I believe that it is necessary to state what I perceive to be a most affective intervention, the rationale for using it, and how I came to be convinced that this method of psychological intervention is both an effective and compassionate means of assisting those individuals struggling so deeply on a daily basis to maintain their humanness.

My path leading to working with those diagnosed with schizophrenia and other serious mental health disorders was a fortuitous one. I applied to several clinical psychology programs across the country. One of those to which I was accepted was Michigan State University. It was there that I met and had several classes and many interactions with the remarkably brilliant Professor Bertram P. Karon. One of the courses conducted by Karon was a course on the treatment of schizophrenia from a psychodynamic perspective. Of course, the main source of information on this topic was his seminal work with Gary R. Vandenbos entitled Psychotherapy of Schizophrenia: The Treatment of Choice.¹ We also had the opportunity to watch Karon conduct several therapy sessions with one of his then current clients (with the clients fully informed consent). After that class, I never thought I would be devoting much of my professional career to the treatment of individuals diagnosed with this life challenging disorder.

My clinical internship took me to the Veterans Administration Medical Center in Ann Arbor, Michigan. I was fortunate to have as my supervisor a most experienced and kind individual, Robert Gunn, PhD. One of my first clients at the hospital was a young Army veteran who was assigned to me through the counseling center. He was a veteran who had his first episode of schizophrenic symptoms while in the service. His symptoms of paranoia and auditory hallucinations continued to intrude into his life on a daily basis. I struggled with how to proceed in treatment, even though I had those courses with Karon. One day while in supervision with Gunn, upon expressing my frustration and confusion, he reminded me to just listen to where the client would take me and to realize that the client would let me know unconsciously the source of his hurt. It was my job to calmly listen and to hear his unconscious begging to be understood.

Upon our next session, the veteran began to talk about the usual concerns that he had: that others were following him, that they were spying on him, watching him and making negative, harsh comments about him. He then said that he knew that they were there outside his window because he saw that they spit on his window. At that point, I remember not knowing how to proceed, but recalled through my education with Karon that these events were somehow symbolic of something in reality and that the actual event that triggered the delusional experience could be identified. I decided to painstakingly go over the day that this spitting occurred. He began with a long story of getting up, getting dressed, eating breakfast, etc. After what seemed like 20 minutes, he began to tell me a story that happened earlier in the day at a school where he was taking a course. He stated very calmly and without any affect, as was his usual presentation, that the teacher blurted out his grade on a paper in front of the whole class. He then continued his story of the rest of the day in a very matter of fact manner. At some point, I stopped him and asked him the usual therapist question, “How did you feel when your teacher said your grade in front of the class?” He dismissed it and said that it was fine or something to that effect. I then used my own feelings of when I heard him tell his story. I wondered with him if he felt hurt, embarrassed, ashamed, and/or angry at his teacher. I then remembered the story about the spit on the window and in an instant it all made sense. I said, “I wonder if you were so angry that you wanted to spit at your teacher?” I also made the connection between seeing the spit on the window and his impulse to spit at his teacher. He looked at me with a sort of dazed, puzzled, but also revelatory look on his face. He neither confirmed nor denied what I had stated, but I knew that I had made the correct interpretation because for the rest of the session he was noticeably more relatable, with significantly less delusional material being presented. He spoke of real life struggles that he was currently experiencing both on the job and in his personal life. This one interpretation did not extinguish his delusional experiences, although I never heard again of spit on his window, but it put us on the path to where we could, at times, discuss the real hurts, traumas, shame, and guilt that he had been carrying around inside for over a decade.

From the Veterans Administration, I accepted a position as a staff psychologist at a major psychiatric hospital in California. In those days, there was one psychologist on a unit with roughly 45 to 50 patients with chronic illness, mostly with some form of schizophrenia or bipolar disorder. It was here that I implemented in full measure the theory and techniques described by Karon and other psychodynamic theorists. I will give one more case example, of which I have dozens, of how listening to the client, understanding their symptoms as symbolic representations of their conflicts, and then making that interpretation for them, at least early on in the therapy when one is both establishing a relationship with them and teaching them about their symptoms, leads to a removal or reduction of symptoms.

One day while meeting with a patient, as we usually did 2 to 3 times per week for about 40 to 60 minutes, he said that his sister was going to come visit him and take him home for a visit. We sat outside the unit and waited. His sister was expected to arrive at 4:30. She arrived around 4:35. They left for the weekend and I wished them well. Monday morning, I arrived to work and we began a session. We walked around the building as was sometimes our custom and talked about his weekend. All of a sudden, I noticed that he was limping. He said that his right leg was numb, he could not feel it, but that there was no pain. He casually mentioned this paralysis and did not seem too concerned. I again asked him about it, when it started, what was going on, etc. We somehow got around to his visit with his sister. I am not sure which one of us mentioned it, but it was brought up that she was late picking him up on Friday. Yes, 5 minutes late. I asked him how he felt about that, and of course he had no feelings about it. I then stated, “Wonder if you felt like kicking your sister because she was late?” As soon as I made that interpretation, he began to walk normally, no limp. I commented on this, pointing out my comment, his possible feelings of anger towards his sister, his unconscious wish to kick her and the resulting paralysis of the leg which he would have used to kick her. As in the previous case presentation, he had no real response, but neither confirmed nor denied my interpretation. We just calmly walked on and the paralysis never returned.

My personal experiences, both in inpatient and outpatient settings, have shown me that a multidimensional approach to treatment is the most effective. Given my proposed position that psychodynamic intervention can an effective treatment, the utilization of antipsychotic medications has given millions of individuals a chance at a fulfilling life. More recently, however, pharmacotherapy of schizophrenia is now taking into account not only the effectiveness of antipsychotics on the debilitating symptoms of the disorder, but of the quality of life that the individual will have while taking these medications. A recent systematic study by Sampogna et al (2023) revealed that “second-generation antipsychotics have a more positive effect on quality of life” and “that long-acting injectable antipsychotics are associated with a more stable improvement in quality of life and with a good safety and tolerability profile.”² As these medications have become more effective in reducing symptoms, they are also becoming more tolerable for the individual taking them. If the adverse effects are more tolerable, than it goes without saying that medication compliance will only increase.

According to Mark L. Ruffalo, MSW, DPsa, in the article “Schizophrenia from the Psychodynamic Perspective,” psychotherapy is “currently underutilized in the management of schizophrenia.” He goes on to say that the psychodynamic method “forms an important part of a bio-psychosocial approach to the most fascinating and complex of human illnesses.”³ These individuals that we clinicians serve deserve the best and most advanced treatments that can be offered, including both pharmacotherapy and those from the different psychotherapy perspectives. All have much to offer. We owe these individuals that much.

I would like to close by acknowledging that there is much to be learned about the disorder identified as “schizophrenia.” The disorder continues to affect roughly 1% of the worldwide population with roughly two-thirds of those affected suffering lifelong debilitating symptoms. Clients deserve mental health clinicians who are well trained in the psychodynamic perspective. Karon used to say to us that if the clinician is well trained in the modified psychodynamic perspective, then positive change can occur. I have found this to be true in my own practice. My experience is that these individuals are desperate to understand their symptoms and are willing to do the hard work necessary to have a meaningful and satisfying life. They also want to be connected to others and it is our job to make this connection possible.

Dr Ledesma is a clinical psychologist in private practice in Huntington Beach, CA.

References

1. Karon BP, Vandenbos GR. Psychotherapy of Schizophrenia: The Treatment of Choice. Aronson; 1977.

2. Sampogna G, Di Vincenzo M, Giuliani L, et al. A systematic review on the effectiveness of antipsychotic drugs on the quality of life of patients with schizophrenia. Brain Sci. 2023;13(11):1577.

3. Ruffalo ML. Schizophrenia from the psychodynamic perspective. Psychiatric Times. February 17, 2023. https://www.psychiatrictimes.com/view/schizophrenia-from-the-psychodynamic-perspective